'Rational' suicide and people with terminal conditions or disabilities.

• Author: Clark, David C.

As a faculty member at a university teaching hospital and a psychologist who specializes in treating mood disorders and suicidal behavior, I believe that the themes and arguments of Derek Humphry and the Hemlock Society oversimplify the important social debate about euthanasia and physician-assisted suicide. For example, Hemlock Society material usually ignores basic facts about the usual course of terminal illness and fails to consider the roles that psychiatric illness in general and depressive illness in particular play in giving rise to suicidal feelings and despair. The suicidal communications of the ill should not always be accepted at face value, without seriously considering the possibility that a person talking about suicide may have several different conflicting wishes that need to be understood before conclusions can be reached about what the person really wants.

When pressed, Humphry points to one brief and obscure warning buried deep inside his book Final Exit(1)--a warning that depressed persons reading his book should put it down and seek professional help. This precaution is inadequate. Furthermore, "loss of insight" is a common symptom of depression, and when present means that the depressed reader has little grasp of the nature or severity of his/her illness until after he/she has recovered.

I should emphasize, however, that I believe Humphry and many Hemlock Society adherents are motivated primarily by compassion for the suffering. Humphry clearly has some understanding of the potential for abuse of "assisted death" practices. But regardless of any good intentions, his writings are full of misleading omissions and distortions. Reliable information about physical illness and suicide ought to be made available to the general public so citizens can join the important debate with access to the salient facts. Any thoughtful and informed discussion about euthanasia, the "right to die," and suicide should include the following information.

In what follows, I will review epidemiological trends to document the scope of the suicide problem, outline what research has revealed about terminally ill persons and persons who die by suicide, and emphasize some clinical features of depressive illness that are often overlooked. At the conclusion, I will make some general comments about issues of mental competence and "rational" suicide from my perspective as a psychopathologist.

Suicide Is a Major Public Health Problem

Suicide is the eighth leading cause of death in the United States, accounting for more than thirty thousand deaths each year. It is a major public health problem, not a narrowly defined psychiatric or psychological problem. When leading causes of death are ranked according to "years of premature life lost," suicide rises in rank order to become the fourth leading cause of death. Those under age twenty-five years make up 16% of the U.S. population and account for 16% of all suicides. Those aged sixty-five years and over make up 12% of the population but account for 21% of all suicides.(2)

Suicide rates in the U.S. are not uniformly higher among older persons. Men aged sixty-five years and over are associated with a much higher suicide rate than other men, but the same is not true for women (Figure 1). Middle-aged women have much lower suicide rates than middle-aged men, and the rate of suicide for women declines after age sixty-five.

Suicide rates in the U.S. are not uniformly higher for those with less access to health care. Caucasian citizens are associated with more education and a higher average income than African-Americans and Hispanics, and consequently Caucasians enjoy better access to health care--yet the suicide rates for Caucasians are consistently two times higher than those for African-Americans and Hispanics (Figure 2),

According to World Health Organization statistics, the U.S. suicide rate is near the middle of the pack on the international scene. Countries with suicide rates consistently ranked among the highest in the world include Switzerland, Sweden, former West Germany, and Denmark-- all of which have sophisticated national health care delivery systems.(3)

The age trends for nonfatal suicide attempt rates reveal a completely different pattern. About 2.9% of the general adult population has made a suicide attempt. Nonfatal attempt rates are highest for those aged twenty-five to forty-four years, lower for those between eighteen and twenty-four years, and lowest of all for persons aged sixty-five years and over.(4) Thus the ratio of nonfatal to fatal suicidal acts is lowest among older persons. Older adults try suicide less often than those in other age groups--and survive the attempt less often.

Characteristics of Persons Who Die by Suicide

The Value of Psychological Autopsy Studies

Until recently, most clinical studies of suicide were based on samples of persons who had made nonfatal attempts (including those who made medically serious or repeated nonfatal attempts) for the simple reason that they remained alive and available for interview. The remaining studies were based on samples of persons who were in some form of mental health treatment for an extended period of time before they died by suicide because detailed observations for the period preceding the suicide were well documented.

More recently, it has become clear that neither of these types of samples is representative of the kinds of persons who die by suicide.(5) Dahlgren(6) and Stengel and Cook(7) were among the first to show that persons who make nonfatal suicide attempts and persons who die by suicide are more nearly different than alike. Now it is well-established, for example, that compared to nonfatal attempters, persons who die by suicide are more likely to be male,(8) more likely to use a gun or a rope to effect death,(9) more likely to have no history of any mental health treatment,(10) and more likely to evidence a major psychiatric illness at the time of death.(11) Yet less than half of those who die by suicide have made a prior suicide attempt.(12) The implication is that only community-based psychological autopsy studies provide investigators with an inclusive or comprehensive overview of the diversity of persons who die by suicide.

The phrase psychological autopsy refers to a procedure for reconstructing an individual's psychological life after the fact, particularly the person's life-style and those thoughts, feelings, and behaviors manifest during the weeks preceding death. It represents an attempt to better understand the psychological circumstances contributing to the death. The essential ingredients of the psychological autopsy method include face-to-face interviews with knowledgeable informants within several months of the death, reviews of all extant records describing the deceased, and comprehensive case formulation by one or more mental health professionals with expertise in postmortem studies.

The first psychological autopsy study was a community-based study of 134 consecutive cases of suicide in St. Louis.(13) In the almost thirty-five years since, there have been only a handful of other community-based psychological autopsy studies of large size,(14) but this tradition of research has made unique and significant contributions to the clinician's understanding of completed suicide.

The Validity of Official Suicide Counts

In the United States, determination of suicide as a mode of death lies in the hands of medical examiners, coroners, or coroner's juries. These determinations are based on customs and legal procedures that vary widely from county to county. Nevertheless, epidemiological studies of the accuracy of reported suicide rates have consistently suggested that the margin of under-reporting is of relatively small consequence.(15) Kleck has shown that even if most accidental deaths by methods similar to those seen in suicides are reclassified as suicides, the net U.S. suicide rate would rise only about 10%.(16)

In Los Angeles, a special psychiatrically trained death investigation team has studied and advised the medical examiner concerning all equivocal cases of death--about sixty out of one thousand deaths annually-for the last thirty years.(17) During this period, 55% to 65% of the equivocal cases were finally certified as suicides.(18) These trends suggest that the medical examiner's initial undercount of true suicides was never more than 5%.

The implication is that while official statistics may consistently undercount the true number of suicides, this undercount is likely to fall between 5% and 10% percent of the true total. Therefore the available community-based psychological autopsy studies are likely to be representative of most suicides.

The Majority of Persons Who Die by Suicide Are in Good Physical Health

There is considerable agreement among the findings from large community-based psychological autopsy studies conducted in far-flung regions of the United States, the United Kingdom, Sweden, and Australia. The major studies all agree in showing that the fraction of suicide victims struggling with a terminal illness at the time of their death is in the range of 2% to 4%.

Nevertheless, there is increased physician contact in the months preceding death: 50% of suicide victims have seen a physician within a month of their death, and 80% within six months. Few of these physician contacts were with mental health professionals. The typical final contact before death was for vague and unrelated physical complaints not warranting any physical diagnosis, and the possibility of diagnosing a mental disorder was rarely entertained.

The body of literature considering geriatric suicides includes epidemiologically based demographic studies,(19) a series of literature reviews,(20) record review studies of medical examiner's records,(21) and clinical case reports,(22) but no psychological autopsy studies until the last three years.

Conwell's recent psychological autopsy study...