Some 55 per cent of young people know of a peer who has attempted or died by suicide, according to The Irish Times/TNS mrbi poll of 15-24 year olds published last week. The darkness of suicide will continue until preventive strategies are based on science rather than intuition or popular belief, writes Patricia Casey.
While it is a striking and frightening figure, perhaps the most unexpected of all those presented in the course of the survey, it has received surprisingly little comment.
Although this survey did not ask those polled how many had ever tried to self-harm or had felt actively suicidal, it is still of immense public interest.
Few apart from mental health professionals realise that suicidal behaviour is contagious and that many such acts are imitative. The fact that such a large proportion of young people know somebody who has resorted to suicidal behaviour places them potentially within this fold.
Copy-cat suicide is not new and has been described in literature. It is known as the Werther Effect after the work of Goethe The Sorrows of Young Werther, published in 1774, which describes the death by suicide of a young man who shot himself because of his love for a young woman. Its publication resulted in an epidemic of suicide leading to a ban in several European countries at that time.
The contagious nature of suicide has been recognised for centuries and even in ancient Greece the proliferation of suicide clusters led to some of the ancient sanctions against the suicide act. Suicide clusters have been described on college campuses, in psychiatric hospitals, in suburban America and in a virtually every country that keeps records of such death patterns.
Quite a lot is known about imitative suicide. It is primarily, but not exclusively a phenomenon of the young and especially of males.
The initial victim need not necessarily have been known personally to those who subsequently imitate the act; merely that there is an identification and emotional affinity with the problem as perceived by the imitator.
Its mechanisms are diverse and whilst imitation itself plays a role, it is also believed that a suicide diminishes the inhibitions and triggers the behaviour in an already vulnerable person.
In addition some adolescents fantasise and believe that the adulation attaching to the suicide of a well-known person will accompany them also, showering on them the attention in death that was denied them in life. The curtailment of suicide, and of suicide imitation, is a matter for the whole of society and not just the medical profession or Government. In particular, the manner and tone of our discourse about suicide is crucial in preventing others from imitating it.
Central to this is the method of reporting and the amount of coverage given in the media; most agree that the content and style of reporting can have an effect for better or worse.
Many media organisations internationally have pledged themselves to a particular approach to coverage of suicide and agree that individual acts should not be glamorised, that it should be placed on inside pages and avoid descriptions of methods or photographs of the site. Most media would say they assiduously avoid breaching these standards.
However, it is possible to glamorise suicide subtly by glorifying those who take their lives or by suggesting that society is honouring the suicidal behaviour of the deceased. This may take the form of describing flags at half-mast, public eulogies that speak of the victim as courageous or focusing exclusively on the victim's positive characteristics, thus giving the impression that the suicide was the act of a well person.
A further problem is that simplistic explanations are offered and suicide may be presented as a tool for accomplishing certain ends rather than the act of a troubled human being, e.g., as a response to exam stress. Sometimes the person is portrayed as a hero, as was Kurt Cobain. There is even the sleeve of a CD by the rock band Rage Against the Machine that shows a monk self-immolating - so glorified is this act of defiance.
In approaching suicide in this way there is a danger that it will be disconnected from its very close association with mental illness, usually depressive illness, alcohol dependence and a troubled soul. Repetitive coverage can be equally damaging since it maintains a preoccupation with suicide in the minds of those who are vulnerable that may be contagious. The media has a responsibility to ensure that coverage is not only not sensational, but is scientifically accurate. The dictum primum non nocere applies as much to the media as to medicine.
On foot of the results of this poll and the tragic evidence given to an inquest in Co Donegal on Monday, it is likely that there will be calls for the Government "to do something" and the most likely suggestion is that school-based suicide awareness/prevention programmes should be put in place. However, the results of such programmes are disappointing and even counter-intuitive.
David Shaffer, a psychiatrist from Columbia University, New York, has examined the results and found that not only were they at best ineffective, they also lead to an increase in suicidal behaviour in some instances. These findings have been confirmed by studies in the US, Canada and Australia.
A withering review of these programmes published in the American Psychologist states: "Many curriculum-based programmes are not clearly founded on current empirical knowledge of the risk factors of adolescent suicide. By de-emphasising or denying the fact that most adolescents who commit suicide are mentally ill, these programmes misrepresent the facts. In their attempt to de-stigmatise suicide in this way they may be, in fact, normalising the behaviour and reducing potentially protective taboos."
Suicide is largely preventable. Already enough is known about the personal and cultural risk factors for suicide; among the latter is social change, including that pertaining to religious belief and practice making suicide an option for the tormented and the ill. For individuals, the association with psychiatric illness including alcohol abuse should clearly point us in one direction only - that is to seek professional help. Certainly Government should deal legislatively with our national love-affair with alcohol but the responsibility extends to all citizens, the medical profession and the media.
Unless and until our preventive strategies are based on science rather than intuition or popular belief, the darkness of suicide will continue to overhang our towns and villages bringing in its wake despair, anger, helplessness and guilt.
Patricia Casey is Professor of Psychiatry at the Mater Hospital/UCD.