Sunday, February 28, 2021

Suicides are not "mental accidents" (thoughts on Ajdacic-Gross et al., 2019)

The so-called "psychotically depressed" person who tries to kill herself doesn't do so out of quote "hopelessness" or any abstract conviction that life's assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certainly unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise...Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the window just checking out the view, i.e. the fear of falling remains constant. The variable here is the other terror, the fire's flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors.  

David Foster Wallace, Infinite Jest

Of course, suicide is often approached from a mental health/psychological disorder perspective. At the same time, suicide can be studied at an epidemiological level, in terms of, for example, national rates over time (questions include whether economic recessions are associated with increases in suicide rates). A provocative paper from a couple of years back took the approach of proposing an interdisciplinary paradigm for suicide research. Although it caught my eye, it doesn't seem to have had much uptake in the scholarly literature; as far as I can see, the review hasn't been cited as yet on Google Scholar (which tends to catch citations from a wide variety of academic sources).    

The authors cite epidemiological research suggesting the association between suicidal ideation, suicide attempts and completed suicide is weaker than one might intuitively expect. They highlight that reasoning often begins with completed suicide and tries to work backwards to explain what caused this outcome, rather than starting with risk factors and working from ideation to attempt to death. This latter approach is important for identifying preventative measures, and also for not underestimating or under-emphasising the greater prevalence of ideation and attempts compared to deaths by suicide (there is evidence of a high lifetime prevalence of suicidal ideation in the general population). 

The authors acknowledge there can be different temporal dynamics to suicide, where some individuals with previous good mental health may die quite suddenly following a severe stressor, whereas others may die following a long struggle with severe distress and previous uncompleted attempts. In the latter circumstances, the authors recognise their paradigm is less applicable. They also recognise a cognitive component to suicidal ideation, relating to appraisals of factors such as whether one has hope for the future. This weakens the idea of a paradigm where suicide is understood as a "mental accident".

At an epidemiological level, the authors draw an analogy with fatal road traffic accidents, where although there are many traffic accidents, very few will be fatal. However, notwithstanding that some fatal road "accidents" may actually represent death by suicide, traffic accidents are generally unintentional. 

Although suicidal ideation may be deliberative, a lack of resistance to such ideation may be much less deliberative. They highlight the importance of broader situational factors such as economic recession and austerity in precipitating suicidal ideation, along with an increase in help-seeking behaviour over the last few decades. However, and perhaps more importantly for the "accident" hypothesis, they also cite immediate situational factors relating to the availability of lethal methods, suggesting that the high impact of easy availability of lethal methods, such as having a firearm in one's household, suggest that completion may be prevented by relatively small hurdles. However, I think the authors would admit that this is more to do with suicidal impulses (of sufficient strength to drive an attempt) sometimes being relatively transient, rather than death by suicide being understood as a "mental accident". 

I'll admit the title of this article caught my attention. Framing suicide as an accident seems highly counter-intuitive. However, this review ultimately left me unconvinced that even a subset of deaths by suicide should be thought of as mental accidents. In my mind, an accident doesn't involve genuine intent, and for a death to be classified as suicide it must surely involve some level of intent. In my opinion, what this article does indicate is that death by suicide involves deliberative suicidal thoughts combined with a loss of control of competing motivations. Although research in suicidology and efforts in suicide prevention may have much to learn from work in the area of fatal accidents that actually are accidental, I fear the authors may have prioritised a provocative title/statement of their thesis over a more nuanced summary of what they are really saying. I hope I'm not just attacking a straw argument here, but I do regret the possible tabloidisation of scholarly publishing, particularly with a subject as serious as this.

Ajdacic-Gross, V., Hepp, U., Seifritz, E. & Bopp, M. (2019). Rethinking suicides as mental accidents: Towards a new paradigm. Journal of affective disorders, 252, 141-151.

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