Tug of War with Death--Let's All Help Prevent Suicide

When winter comes, people's mood darkens like a winter's haze. With loss of appetite, insomnia, and an inability to concentrate, the body becomes listless and the "depression index" seems to rise.

In the space of a few short months, a university student, a high ranking police officer, and a famous university professor chose to jump off high buildings, while an unemployed man committed suicide by igniting a gas canister and a soldier killed himself with charcoal fumes. The numerous suicide cases cast a dark shadow over all of society.

Given that most suicidal people suffer from depression and that winter is a season conducive to depression, is suicidal behavior brought about by depression?

art:chou Min-hua

My night grows endless

Medical science believes that the changing of the seasons has a profound influence on human emotions. Because nights are longer in winter, at night the brain's pineal body tends to secrete more melatonin, a hormone that helps people fall asleep. At daybreak, the production of melatonin gradually decreases and the body begins to perk up. But on winter mornings, there is often not enough sunlight, and melatonin remains in the body, making people feel drowsy and even dejected. Because in winter the days are short and the nights are long, people who live in northern European latitudes tend to suffer from "winter depression."

Comparing suicide rates, countries can be divided into three categories based on their suicide rates: low, with less than ten suicides per 100,000 people (such as Muslim countries); medium, with 10-20 suicides per 100,000 people (such as the UK and the USA); and high, with more than 20 suicides per 100,000 people (countries in Eastern Europe and Scandinavia).

What about Taiwan? Dr. Cheng Tai-ann of the Institute of Biomedical Science, Academia Sinica, says: "In the past 50 years, Taiwan's suicide rate has exceeded ten per 100,000 in two years out of three, and almost half the time suicide has been among the ten leading causes of death." The worst stretch was 1980-86, when the figure exceeded 10 per 100,000 people every year; the worst single year was 1964 (18).

As medical science advances, the human genetic code has been unraveled gene by gene, and the complex brain makeup of people who commit suicide is also gradually becoming clearer.

Analyses of suicide have shown that the most common contributing factor is mental illness, but of the broad range of mental illnesses only a few display a close link to suicide. Among these are depression, bipolar disorder, schizophrenia, borderline personality and antisocial disorders, alcoholism, and drug abuse. Studies conducted in the West have shown that 90% of successful suicides were previously diagnosed with mental illness.

Figure 2: Taiwan's suicide rate by age

Serotonin deficiency

Suicide has a long history. The New Testament records that Judas Iscariot, the apostle who betrayed Jesus, hanged himself out of remorse. When Japanese samurais were defeated in battle, their honor code dictated that they commit seppuku, an act that became a solemn and stirring symbol of the Japanese people. But it is only in modern times that science has gradually begun to solve the mystery surrounding the physiological mechanisms of suicide victims.

Scientists have long assumed that "compulsive" personalities are typical suicide candidates. Therefore, in the last two decades research has focused on finding biological clues to "compulsiveness."

In March 2003 the Chinese edition of Scientific American magazine published an article entitled "Suicide: Why Do They Do It?," which pointed out that research by American scientists has shown that a type of neurotransmitter in the brain-serotonin-is related to emotional stability in humans, and that people suffering from depression who exhibit aggressive behavior, as well as people with compulsive and obsessive personalities, have lower levels of serotonin than normal people. Researchers at Columbia University who have collected brain samples from suicide victims, which they have dissected and analyzed for chemical and genetic abnormalities, state: "The serotonin system in the brain of suicide victims is defective. In very serious cases no amount of Prozac can save them."

Cheng Tai-ann has studied the suicide phenomenon in Taiwan for more than 20 years. He once investigated 113 suicide cases in eastern Taiwan, visiting victims' families to gain an understanding of their life histories and psychological condition. What he found was that in more than 90% of cases, people who died from suicide had suffered from more than one psychiatric disorder, and more than 80% of them from severe depression. Forty percent had been alcoholics or drug addicts and 60% had had a personality disorder.

According to Cheng, research in Taiwan and abroad has consistently demonstrated that severe depression, alcohol and drug addiction, psychological instability and personality disorders, and suicidal behavior by close blood relatives are all clear contributing factors to suicide. Moreover, Dr. George Brown, a fellow of the British Academy, stresses that the experience of loss events also plays a decisive role as a catalyst for suicide.

Loss events can be the loss of one's health, such as a fatal disease, an intractable chronic illness, or physical disability; the loss of a loved one, such as the death or departure of a close friend or relative; the loss of one's job or property; or seeing one's cherished hopes dashed, such as suddenly finding out that one's spouse has a lover. In Taiwan, more than 80% of suicide victims previously experienced loss events, and 60%, i.e. the majority, kill themselves because they have "seen their cherished hopes dashed."

Putting it in a nutshell, Dr. Cheng says, "A mentally healthy person does not commit suicide." People suffering from severe depression run a 40 times higher risk of suicide than psychologically healthy people. For people who have experienced loss events, the risk of suicide is six times greater, for those with a close relative who has committed suicide it is five times greater, for people with compulsive personalities it is four times greater, and for drug addicts and alcoholics it is three times greater. All of these categories of people have a high risk of committing suicide.

Taiwan is a small, densely populated society in which people pay great attention to every detail of human relations. Temples and fortune tellers are found everywhere and provide an alternative form of psychological counseling.

No hope for the future

Professor Hsu Wen-yau of the Department of Psychology at National Chengchi University points out that although a large proportion of suicide victims suffer from depression, depression and suicide ought not to be equated, because otherwise it will prove very difficult to face squarely and debate the many other types of suicide.

Further analysis reveals that the suicide rate has always been closely bound up with economic factors, and that Taiwan is no exception. For example, Taiwan's suicide rate peaked in 1982 (with 12 suicides per 100,000 people) and began to decline thereafter, reaching its lowest point in 1990, at a time when Taiwan was experiencing an economic boom and its industry was thriving. But the suicide rate began to rise again in 1995, and in 1997, during the Asian economic crisis, it became once again one of the ten main causes of death in the country.

It is worth noting that in recent years the suicide rate has risen in tandem with the rate of unemployment. In the male population aged between 15 and 44, it is currently the third cause of death. Taiwan's suicide statistics amply demonstrate that economic factors have a direct impact on men's psychological and emotional wellbeing. In other words, the economic recession has already exerted enormous pressure on men who shoulder a heavy financial responsibility for their family.

Concerned about young people and teenagers who commit suicide, Hsu Wen-yau says that when males aged 45 to 50 kill themselves, they harm the generations above and below them. Their children between the ages of 15 and 24 are still developing their personality and values, or are embarking on their professions. The sudden death of the head of the family has a huge impact on the entire family, and youngsters may end up committing suicide because they "lose hope in the future."

A Western poet once said, "Any man's death diminishes me." Though life is far from perfect, "it is the crack in the universe that allows the ray of light to shine through."

Is suicide contagious?

Suicide is evidently a serious problem, but most people ought not to be excessively worried or alarmed about it.

Cheng Tai-ann says that what most people know about suicidal behavior they get from personal experience and reports in the media. When the media vie with each other to report cases of suicide, it is easy to get the impression that a "wave of suicides" is upon us. Dr. Cheng stresses that when the news media report cases of suicide, they tend to put forward monocausal theories of people who have been disappointed in love, have lost their job, or are under excessive academic pressure, but in fact very few suicides can be attributed to a single cause.

"Suicide is brought about by a pathological mindset or by suggestion, such as the notion that 'living is so painful, I might just as well put an end to it sooner rather than later.'" Cheng points out that although such ideas have a contagious element about them, people who are mentally healthy or who have a strong "psychological immunity" will not easily be "infected" by suicide reports. But people who are themselves suffering from severe depression or who have suffered a serious setback in life, are more likely to be contaminated by an unhealthy suicidal frame of mind and to be unable to free themselves from it.

In his book Night Falls Fast: Understanding Suicide, Professor Kay Redfield Jamison describes many examples of suicide phenomena that most normal people would find hard to imagine. Mt. Mihara is an active volcano on Oshima Island which was virtually unknown to the Japanese public until 1933. One day, university students from Tokyo climbed to the lip of this volcano, and one of them told her friend that she wanted to jump into it, because she would immediately be turned by the fire into beautiful wisps of smoke that would be lifted up to heaven. When the story of this suicide got around, throngs of people from all over Japan rushed to Mt. Mihara, and the police had to set up a 24-hour detail and a wire fence to guard the volcano from people bent on killing themselves.

Because there are relatively few people with a pathological personality in society, many scholars believe that the sensationalist depiction of suicide in the media, books, and films can in fact lead to an increase in the number of suicides, especially among the impressionable young.

To reduce the possibility of "suicide contagion," in 1994 the US Centers for Disease Control and Prevention established a set of recommendations for the media: do not put forward simplistic explanations of suicide; do not report suicides in a repetitive manner; and do not describe suicide as a tool for achieving a certain goal, such as hinting that someone committed suicide to get back at the person who jilted them or to retaliate against their parents' discipline, because this can cause people with suicidal thoughts to consider suicide a method of solving their problems.

Because of the close link between severe depression and suicide, Taiwanese people concerned about depression established the Taiwan Sunflower Association, which encourages people suffering from this disease to see a doctor in time, take their medicine, and to participate in group therapy.

Everyone can help prevent suicide

Given that suicide is the result of interrelated internal and external factors, does it really have outward signs that can be identified beforehand? And how can it be prevented?

Dr. Lee Ming-been, superintendent of the Taipei City Psychiatric Center, points out that many people believe that suicide is a spur-of-the-moment act conceived and carried out on an impulse, and as such cannot be prevented, but research shows that 30% of unsuccessful suicides try to kill themselves again, of whom 20% succeed within a year. Therefore, if the healthcare system can get suicide patients to undergo counseling and treatment after their first attempt, the rise in the suicide rate could be effectively checked.

To this end, in October 2003 the center established the Suicide Prevention Center. It also appointed "informers" in police bureaus, fire brigades, and neighborhood hospitals to build a protection net. As soon as the center receives an attempted suicide report from an emergency ward, it tries to conduct a thoroughgoing follow-up and to provide psychological counseling to the patient to prevent another suicide attempt.

Dr. Cheng points out that in Taiwan 58% of people who killed themselves visited a hospital in the three months prior to the suicide, but only 13% sought help from psychiatric departments, a figure well below that found in other countries.

Because many people in Taiwan know little about mental disorders, when they experience symptoms of depression such as insomnia, loss of appetite, and excessive fatigue, they often take them to be common physiological problems, and waste much mental and physical energy in cardiology, gastroenterology, and other hospital departments, but fail to seek psychiatric help. In order to remedy this situation, last year the Department of Health launched a "Taiwan-style family doctor" program directed at Taiwan's 16,000 general practitioners, 9000 clinics, and first-year residents in every major hospital. The program offers training in psychiatry and teaches participants to identify potential depression patients and to promptly refer them to a psychiatry department.

Hsueh Jui-yuan, deputy director of the Bureau of Medical Affairs in the Department of Health, says that "Our future task is to integrate suicide prevention into the workplace." According to Hsueh, in this age of global competition industry unduly emphasizes the law of the jungle. An A is not enough; you have to get an A+. There is so much pressure on the workforce that Taiwan's suicide rate among young people has doubled in the past decade. Yet because young people work such long hours, they often put off going to the hospital, which is why they are the group healthcare providers find it most difficult to reach. In fact, many scholars think that human-centered management does not necessarily result in reduced competitiveness. There can definitely be communication between individual psychological needs and business management.

Research shows that more than half the people who kill themselves visited a hospital in the three months prior to the suicide, but only 13% sought help from psychiatric departments. Thus, being aware of one's own psychological state and seeking professional help in good time is an effective way of preventing suicide.

No man is an island

"What is the meaning of life? To my mind, no sooner is a human being born, than he or she is getting ready to die. Whenever I think about my own future, I see boundless darkness. I am determined not to waste society's resources...." Thus reads a note left by a college student who killed himself by jumping off a building.

Half a century ago, most people who committed suicide were around 65 years old. In the past 20 years, the average age of suicide victims has gradually dropped. Why do young adults and teenagers who have barely started their lives wallow in their own pain and tragedy, and take the ultimate step?

"In the past, society was poor and unenlightened, and nothing had greater meaning than being alive. Today, because staying alive is not hard, people are unable to find meaning in life itself. Yet we must look for meaning in life itself," comments social critic Nanfang Shuo. He notes that feelings of fatigue, emptiness, waste, and futility with respect to life have become an unavoidable existential question for young men and women. Life is not perfect, but as a poet put it, "It is the crack in the universe that allows the ray of light to shine through."

A passion for life must be kindled and guarded with care. The Train of Life is forging ahead. We may be unable to truly appreciate the pain that emotionally disturbed people feel, yet none of travels alone through this life. By expressing our love and concern in a caring look, we can bring a little hope into their world.

Main symptoms of severe depression: Have you experienced five or more of the following symptoms for at least two weeks?

1. Insomnia or drowsiness almost every day.
2. Noticeable increase or loss of appetite or weight.
3. Difficulty in concentrating or thinking clearly; forgetfulness.
4. Feeling tired and listless.
5. Feeling dejected most of the time and every day.
6. Losing interest in most things in life (and often feeling this way).
7. Strong feelings of self-reproach, regret, shame, and worthlessness.
8. Repeatedly thinking of death and suicide, or displaying suicidal behavior.
9. Sluggish or hurried in speech and actions, so much so that other people notice.

Warning signs of self-harming and suicidal behavior in children, teenagers, and young people:

1. Linguistic indications: Expresses the intention to kill him- or herself, either directly in spoken words or in essays or poems, e.g. "Nobody would care if I died; maybe things would be better without me."
   
   
2. Behavioral indications:
   *Sudden and marked changes in habits or academic performance, e.g. loss of appetite, sleeplessness; becomes less lively, does much worse in school.
   *Atypical behavior, e.g. sudden high spending by someone usually thrifty. Gives away treasured possessions; gives others instructions on how to dispose of belongings.
   *Expresses longing for life after death and likes to talk about this subject.
   *Unexplained wounds on the body, e.g. cuts on wrists; alcohol or drug dependency, taking sleeping pills.
   
   
3. Environmental indications:
   *End of an important relationship, such as the death of a close relative, or a serious quarrel with or separation from a close friend.
   *Major change in family life, such as financial difficulties or moving to a new home.
   *Coping poorly with surroundings, and therefore lacking confidence; afraid of going to school and repeatedly saying that he or she can't go to school.
   
   
4. Other indications:
   *Withdrawal from usual social group.
   *Signs of depression.
   *Appears dissatisfied.
   *Disrupted sleeping and eating patterns; insomnia, apparent fatigue; physically indisposed or ill.
   
   

Help line:
Lifeline Association nationwide number: 1995

Sources: Taipei City Psychiatric Center; Cheng Tai-ann, Academia Sinica; Professor Hsu Wen-yau, Department of Psychology, National Chengchi University.