Night Falls Fast: Understanding Suicide

Kay Redfield Jamison, a clinician and researcher who has manic-depressive illness (also known as bipolar disorder, a condition characterized by alternating episodes of mania and severe depression), brings both scientific expertise and personal experience to the subject of suicide. Jamison nearly died from a suicide attempt at age 28. In this book, she examines why people kill themselves, why suicide ranks among the most significant public health problems in the world, and how it can be prevented. She draws on clinical research, neurobiology, genetics, history, and the words of those who attempted or died by suicide to build a comprehensive account of the suicidal mind.

Jamison opens with a personal prologue. She recalls an evening with her friend Jack Ryan, who also had manic-depressive illness, during which they made a pact: If either became deeply suicidal, they would meet at Ryan's Cape Cod home, and the nonsuicidal one would have a week to argue for life or arrange hospitalization. They also agreed never to keep a gun. Jamison privately doubted the pact would hold, since during her own suicidal episodes she had never once picked up the phone to ask for help. Years later, Ryan shot himself without contacting her; she had been dangerously suicidal in the interim and had not called him either. This opening establishes her central argument: Suicide overpowers rational plans, good intentions, and love.

The book's first section surveys the history, definition, and scope of suicide. Jamison traces attitudes toward self-inflicted death from ancient societies that accepted altruistic suicide among the elderly and sick, through the Catholic Church's condemnation, to the gradual recognition that suicide is a consequence of mental illness. She adopts the Centers for Disease Control and Prevention (CDC) definition, which requires evidence that the injury was self-inflicted and that the individual intended to die. She establishes the scale of the problem: 30,000 Americans die by suicide each year, suicide is the third leading cause of death among young people in the United States, and suicide among the young has at least tripled over the past 45 years. Suicide killed nearly twice as many young American men as the Vietnam War during the same period.

An extended essay profiles Drew Sopirak, an Air Force Academy cadet regarded as the most respected senior in his class. Weeks before graduation, Sopirak experienced his first manic episode, complete with grandiose delusions and paranoia. Diagnosed with manic-depressive illness, he lost his commission and his dream of becoming a pilot. After a year of relative stability on medication, Sopirak struggled deeply with the stigma of his illness and found himself unable to discuss it with anyone. In November 1995, he stopped taking his medications and deteriorated rapidly. In January 1996, five days after discharge from a psychiatric hospital, the 23-year-old drove to a Delaware gun store that required no waiting period, bought a revolver, and killed himself. His family's funeral notes concluded that his illness moved faster than his acceptance of it.

Jamison's exploration of the psychology of suicide examines suicide notes, cognitive constriction (a depression-driven narrowing of thought that eliminates the ability to envision alternatives to death), and hopelessness. She argues that most notes are surprisingly mundane and that the vast majority of suicides occur in the context of psychiatric illness. She presents research by psychiatrist Aaron Beck demonstrating that hopelessness, the pervasive belief that nothing will improve, is one of the most consistent predictors of eventual suicide. Depression shatters mental flexibility, narrows perceived options, and makes death seem like the only solution. To illustrate, Jamison includes journal excerpts from Dawn Renee Befano, a 20-year-old journalist who chronicled weeks of escalating despair before drowning herself.

The section on psychopathology establishes that 90 to 95 percent of people who die by suicide have a diagnosable psychiatric illness. Mood disorders, schizophrenia, personality disorders, and substance use disorders are most closely associated with suicide. Jamison describes the paralyzing horror of severe depression through accounts by novelist William Styron and others, and contrasts it with the volatile energy of mania. She identifies mixed states, in which depressive and manic symptoms coexist, as particularly lethal. Recovery from depression is paradoxically one of the highest-risk periods, as returning energy may enable individuals to act on previously frozen suicidal impulses. Substance abuse compounds every risk: Two-thirds of those with manic-depressive illness have a serious substance use problem, and the combination of alcohol and depression is implicated in the majority of all suicides.

A second essay recounts the 1995 death of Margaret Davis King, a homeless woman with paranoid schizophrenia who was killed by lions after entering their enclosure at the National Zoo in Washington, D.C. Jamison uses the case to indict the deinstitutionalization policies of the 1960s, which released hundreds of thousands of people with severe mental illness onto the streets without adequate community support.

Turning to biology, Jamison examines the genetic and neurobiological underpinnings of suicide. Family, twin, and adoption studies make a strong case for hereditary influence: A study of the Old Order Amish found that just four families accounted for 73 percent of all suicides over a 100-year period, and twin studies show significantly higher concordance (both twins sharing the same outcome) for suicide among identical twins than nonidentical ones. Jamison focuses on serotonin, a brain chemical implicated in depression, aggression, and impulse control. More than 20 studies link low serotonin metabolite levels to increased suicide risk. Animal studies confirm this: Rhesus monkeys with low serotonin levels are more likely to be impulsively aggressive and to die from violence. She presents psychiatrist John Mann's "Stress-Diathesis" model, which holds that predisposing biological factors establish a threshold for suicidal behavior while precipitants such as psychiatric illness or personal crisis trigger the act.

A third essay addresses the death of explorer Meriwether Lewis, who led the Corps of Discovery across the American continent from 1804 to 1806. Jamison argues that Lewis's death by gunshot in 1809 was almost certainly suicide, supported by his family history of depression, heavy drinking, two prior suicide attempts, and eyewitness accounts. She contends that historians who proposed alternative explanations reflect an unwillingness to accept that a courageous person could die by suicide.

The book's final section addresses treatment and prevention. Jamison identifies lithium as the most effective antisuicide medication: A review of 28 studies involving more than 17,000 patients found that untreated patients were nearly nine times more likely to die by suicide or make an attempt. She discusses antidepressants, antipsychotics (medications that reduce psychotic symptoms), and electroconvulsive therapy (a procedure that uses electrical stimulation to treat severe depression), emphasizing that depression remains grossly underdiagnosed and undertreated. Psychotherapy alongside medication is essential, as studies show combined treatment is more effective than either alone. Treatment noncompliance is a pervasive problem: Many patients stop taking medications because of side effects, stigma, or a belief they are no longer ill.

At the public health level, Jamison examines strategies ranging from physician education to restricting access to lethal means. She documents the contagious quality of suicide and the role media coverage plays in promoting it. She argues that gun control is a critical prevention measure, noting that firearms account for more than 60 percent of U.S. suicides. She describes the development of a national suicide prevention strategy under Surgeon General David Satcher, whose 1999 report was the first on suicide in the two-hundred-year history of his office.

The final chapter examines the devastating impact of suicide on survivors: the guilt, confusion, and enduring grief experienced by parents, siblings, spouses, children, and friends. Jamison argues that the suicidal mind's distorted reasoning makes death seem like a gift to loved ones rather than a burden. She emphasizes the importance of telling children the truth about a parent's suicide, warning that a "conspiracy of silence" causes lasting harm.

In a brief epilogue, Jamison reflects on the difficulty of writing the book and her deepened impatience with the gap between knowledge and action. She describes keeping on her desk a photograph of Drew Sopirak and a line from a Douglas Dunn poem: "Look to the living, love them, and hold on" (311).