Not all of these men and women are depressed.
Many thousands of Americans kill themselves every year. It is said that for every successful suicide, there are ten men and women who attempt suicide. And for every one of those, there are ten who think of killing themselves, but do not. It is usually presumed that the underlying cause of such thoughts is depression; and that is usually the case. But not always. Here are some of the feelings expressed by suicidal patients.
- Most commonly, depression. The anguish present in a major depression is something more than a profound feeling of sadness. Patients who have suffered from other serious diseases, such as cancer, have told me depression is worse. They speak of an enveloping blackness which shuts everything else out. It is so painful that they feel impelled to bring it to an end—even by ending everything. Even so, depression must be accompanied by a sense of hopelessness in order to lead to suicide. And even then, other considerations, such as concern for surviving children can deter the suicidal person. Why someone who has been depressed before and responded to drugs before should feel hopeless is not clear; but sometimes the suicidal person exaggerates and misperceives his or her circumstances. Sometimes, then, a psychotherapist can point to a way out. There are other ways besides suicide of dealing with family disputes or professional failure.
- “They will be sorry when I’m dead.” The so-called suicide gesture, which is really an attempt to manipulate others by threatening suicide, may on occasion go further than intended and actually result in death. The wrong combination of relatively harmless drugs can be fatal. Implicit in such an attempt is the sense that no one will otherwise respond to the wishes and needs of that person.
- Schizophrenia will sometimes present with delusions of persecution so severe that suicide seems the only way out. Sometimes, these suicides do not reflect a desire to die, but rather an attempt to get away—by jumping out of a window or shooting at a policeman.
- “You can’t stop me.” A young man told his parents that they could not control him. If he wanted to, he could kill himself; and they could do nothing about it. They certainly tried. They had him hospitalized and restrained repeatedly. Finally, when he eventually got out of the hospital, he threw himself in front of a train.
- This is the motivation behind those who kill former lovers and then themselves. It is the reason why someone sets out to murder his fellow workers and then himself. I think it is one of the feelings that impel suicide bombers. It is an attempt to get even at last. Revenge is more important than life itself. It is as if their purpose is to kill others and they, themselves, are simply collateral damage. Some individuals hang themselves intentionally where family members will find them.
- Certain confusional states such as delirium tremens or drug intoxication can so disturb the individual’s behavior that he kills himself by mistakenly walking into the middle of traffic or setting himself on fire. This sort of death, however, might more reasonably be described as unintentional.
- The loss of certain critical people—a parent or a spouse—leaves some individuals entirely bereft. For those who believe there is some sort of afterlife, death represents a chance to be once again with those missing family members. I think it is in part loneliness that leads some groups to commit mass suicide, in order, for instance, to join space travelers on a passing comet. And, of course, to be with each other forever.
- Disgust with oneself. The feeling of dissatisfaction with oneself that many feel because of an inability to live up to some moral imperative, such as sexual abstinence of one sort or another, or failure, or simply a physical abhorrence of themselves, can rise to an intolerable degree. Some suicides seem to represent a desire not just to be dead, but to obliterate oneself altogether, such as by jumping off a building. Of course, it is not always self-loathing that leads someone to jump off a building. Sometimes it is simply that buildings are convenient.
- Incomprehensible to most people, there are some who feel humiliated by what seem the ordinary failures of life; and they choose to kill themselves. The discarded lover is an example. I have seen students in high school make a suicide attempt because they have received an unforgivable academic mark, such as a B.
- Feeling entirely helpless and at the mercy of others may become intolerable. Hermann Goering killed himself by taking poison the day before he was scheduled to hang. It was a way of reclaiming control over his life. Some dying patients choose to kill themselves, for the same reason– sometimes when they are only under the impression that they are dying.
- Loss of self. Because of illness or of isolation, there may be a disintegration of a sense of self. Living then becomes unimportant and not worth preserving. Sometimes individuals can lose themselves into a larger purpose, such as a national or religious identification. Religious martyrs make plain that being true to their faith matters more to them than life or death.
- To be famous, spectacular, remembered. Feeling insignificant, certain individuals choose to die flamboyantly, by flying a crowded airplane into a mountain or by jumping from a theater balcony.
- Out of a mistaken and misdirected attempt to “get out of the way” of others and, therefore, make the lives of those other persons better. Sometimes these concerns are heartfelt. Often, however, underneath the surface of such seemingly altruistic thoughts are spite and resentment.
Of course, these motives overlap. Suicide, like all human behavior, results from a confluence of different and sometimes conflicting purposes. People can have different concerns at the same time.
The situations I describe above are all irrational. But it is sometimes said that there can be a rational suicide—that sometimes in the face of a painful and incurable illness, it is reasonable to kill oneself. Yet, it is very common for people to know that they are about to die, and still very few choose to hasten the matter. I think, as a matter of principle, that everyone should have the right to choose how to live, as far as they can, and how to die, as far as dying is under their control; but only if they are in their right mind. Someone may choose to walk along the edge of a cliff—and be allowed to– but not if that person is drunk! If someone is depressed, that person should be prevented from killing himself/herself. It might be reasonable to presume that someone facing a painful death is making a rational choice for suicide; but my experience suggests that is often not the case. Someone seemingly rational—and opting for suicide—is very likely not to feel that way after being treated with anti-depressants. Such, at least, is my experience. If all such measures have been taken, however, that person—and all of us—should, in the end, be allowed if so determined to choose suicide in the face of a more terrible alternative. (c) Fredric Neuman M.D.