Suicidology: A Comprehensive Biopsychosocial Perspective

by Ronald W. Maris
Guilford, 2019, 554 pages

Reviewed by T. Nelson

My philosophy is that you need to know as much as possible about the things that can kill you. That includes diseases, toxic chemicals, poisonous plants, meteors, and, yes, suicide.

Suicide is the toughest one to think about, let alone to read about. But being able to spot the risk factors can help you save someone's life—or maybe even your own. If you're going through this, or know someone who is, I can't imagine a more important topic, or a more important book.

Only 15% of suicide victims leave notes, and they often make plans and appointments for times after they intend to kill themselves. That's because it's not a planned behaviour, but an act of desperation, planned for years—what Maris calls a suicidal career—but executed on impulse. Maris writes “There is almost never a desk calendar that reads, ‘Kill myself next Tuesday at 4 P.M.’”

These days cognitive behavioral therapy (CBT) has completely displaced psychotherapy, but psychiatrists mostly just prescribe drugs. Indeed, after reading the section on mental disorders and their treatment (sometimes coerced), wherein Maris quotes uncritically from the DSM-5 and praises ECT, one wonders why a depressed patient would ever risk seeking psychi­atric treatment. (I still agree with T. S. Szasz on many issues. In fairness, Maris also cites Szasz's theories.) But just as with cancer patients, the primary goal in modern medicine is to keep them alive whatever the cost.

Full-blown depression can actually protect the patient for a time by giving them so little energy they can't take any action. By contrast, a type of bipolar disorder called BP II, where the depression comes and goes, raises the risk of suicide by 28-fold, even more than MDD (major depressive disorder). Maris says 15–19% of bipolar patients complete suicide.

Antidepressants are bad for bipolar patients, and ironically, often bad for depressed patients as well: they can induce suicide by energizing the patient physically, what doctors call a change in vegetative symptoms, before mood symptoms improve, thus giving the patient a window of opportunity to commit suicide. This is because suicide is a violent act that requires aggression—hopelessness and depression alone, though they are strong risk factors, aren't enough. He also says that insomnia in the last third of sleep is a risk factor for suicide.

He quotes Aaron T. Beck, the inventor of CBT, as saying that hopelessness is more suicidogenic than depression, but depression generates hopelessness and dichotomous rigid thinking, which makes the patient think that suicide is the only alternative.

Maris divides the causes of suicide into three types in terms of increasing proximity to suicide:

1. Predisposing factors: Punitive parenting, history of abuse as a child, social violence, history of suicide in the family, and history of depression or schizophrenia.
2. Risk factors: Personality disorder, drug abuse, impulsivity, cognitive rigidity, and isolation.
3. Trigger factors: Depressive episode, physical illness, hopelessness, stress, retirement.

Even so, the vast majority of those of us who have these factors never commit suicide. An important goal is to find out how these individuals differ from their less fortunate comrades.

An example was Silvia Suarez, a healthy 30-year-old with few risk factors. In 2006 she made a paranoid-sounding phone call to her sister and was found dead by exsanguination three days later with two empty bottles of paroxetine (Paxil). Maris suggests an adverse reaction to Paxil and maybe an overdose. These SSRIs play around with monoamines (mainly 5-HT) in the brain; it sounds to me like a clear case of SSRI overdose inducing psychosis, which is somewhat unusual.

According to Maris, the anticonvulsant/anti-pain drug gabapentin (neurontin) and benzodiazepine hypnotics (commonly used as tranquilizers) reduce brain levels of 5-HT and epinephrine, which also increases suicide risk. I should point out that some medical studies dispute the gabapentin claim. Reducing the levels of excitatory neurotransmitters in the brain is known to lead to depression (I'll explain how that works in my lecture on depression, which I'll post soon).

But there is a lot of low-quality research on this topic out there. In 2004 and 2006 the US FDA put a black-box warning on antidepressants, citing a correlation between their use and suicidality in people up to age 24. But as Maris points out [p.64], such a correlation might be expected from their use in treating depression. According to some reports, they can lower your dopamine levels or even block all emotions, making you emotionally numb. They've also been shown to inhibit your ability to cry. This might seem like a blessing to some, but we under­stand too little about the mind to be sure.

Maris says the annual US male and female suicide rates are 20.6 and 5.7 per 100,000; but he also shows bar charts where the rate is 60, and over 160 for widowed white males [p.110]. If true, this equates to an extraordinarily high lifetime risk. The CDC says that 1.3 million people in the USA attempted suicide in 2016. One in 28.8 succeeded, leading to 45,000 deaths. The WHO claims that worldwide there are about 800,000 deaths by suicide each year.

Maris says suicides aren't triggered by unusual stress; rather, he agrees with Motto, who wrote in 1992 that gradual, lifelong repetition and accum­ulation of stressors breaches an adaptive threshold, so that friends might not notice anything special about the victim's life situation.

Most people thinking about suicide still want to live. At some point, their motivational calculus crosses that crucial 50% line where dying seems better. If so, it wouldn't take much to convince them to live a while longer—maybe an interesting book or movie or football game on the horizon. Culture, when it is creative and vital, pulls people out of themselves and gives life meaning. Our actors, writers, and artists are much more important than they realize.

Thus, perhaps the most illuminating sections are the case histories of famous people who committed suicide. These include Ernest Hemingway, whose father, sister, brother, and granddaughter Margaux all committed suicide; Virgina Woolf, Sylvia Plath, Marilyn Monroe, Sigmund Freud, and Robin Williams. Vincent van Gogh, Kurt Cobain, Anne Sexton, Mark Rothko, and Abbie Hoffman also were victims, as were Alan Turing, Kurt Gödel, Ludwig Boltzmann (the father of statistical thermodynamics), Valeri Alekseevich Legasov (who got radiation poisoning investigating the Chernobyl accident), Edwin Armstrong (inventor of FM), and George Eastman.

Most of the case histories are presented sympathet­ically. I recommend having a Kleenex box handy while reading the chapter on suicide notes.

The father of suicidologist Thomas Joiner, whose theory Maris cites extensively, committed suicide, as did Maris's own father. Maris doesn't say much about this, though it obviously influenced his choice of career. But a son who resembles his deceased father is a living reminder to the surviving parent, who may be consumed with guilt or the object of suspicion from others. I personally know of a case where the surviving parent believed that suicide is hereditary and set out to prove it by relentlessly abusing and attacking the child in order to convince others that the suicide was the result of some genetic weakness and therefore not her fault. (She actually succeeded in driving the kid into a clinically depressed state.) This factor should be considered when evaluating the question of heritability of suicidal traits. Could a similar dynamic explain the Hemingway suicides? We may find that many of these so-called suicidal traits are actually a stew of poisonous family interactions triggered by a single event.

However, this is not a personal account or an exploration of the psychodynamics of suicide but a dispassionate, fact-filled textbook. Despite being a single-author work, it is quite repetitive, though well researched, and with very little psychobabble.

See also my article Why do so many men commit suicide? here.

apr 18, 2019. edited apr 19 2019