The Noonday Demon (45 page)

Attempts to define suicidal depression have been singularly fruitless. No strong correlation exists between the severity of depression and the likelihood of suicide: some suicides seem to occur during mild disorders, while some people with desperate situations cleave to life. Some people in the inner cities have lost all of their children to gang violence, are physically disabled, are starving to death, have never known a minute of love of any kind, and yet cling to life with every ounce of energy in them. Some people with every bright promise in their life commit suicide. Suicide is not the culmination of a difficult life; it comes in from some hidden location beyond the mind and beyond consciousness. I can look back now at my own little para-suicidal period: the logic that seemed so abundantly reasonable to me at that time now seems as alien as the bacteria that gave me pneumonia a few years earlier. It is like a powerful germ that entered the body and took over. I had been hijacked by strangeness.

There are fine but important distinctions between wanting to be dead, wanting to die, and wanting to kill yourself. Most people have from time to time wished to be dead, null, beyond sorrow. In depression, many want to die, to undertake the active change from where they are, to be freed from the affliction of consciousness. To want to kill yourself, however, requires a whole extra level of passion and a certain directed violence. Suicide is not the result of passivity; it is the result of an action taken. It requires a great deal of energy and a strong will in addition to a belief in the permanence of the present bad moment and at least a touch of impulsivity.

Suicides fall into four groups. The first group commit suicide without thinking through what they are doing; it is as dire and unavoidable to them as breathing. These people are the most impulsive, and the most likely to be spurred to suicide by a specific external event; their suicides tend to be sudden. They make, as the essayist A. Alvarez has written in his brilliant meditation on suicide,
The Savage God,
“an attempt at exorcism” of the pain that life can blunt only gradually. The second group, half in love with easeful death, commit suicide as revenge, as though the act were not irreversible. Of this group Alvarez writes, “Here’s the difficulty about suicide: it is an act of ambition that can be committed only when one has passed beyond ambition.” These people are not so much running away from life as running toward death, wanting not the end of existence but the presence of obliteration. The third group commit suicide through a faulty logic in which death seems to be the only
escape from intolerable problems. They consider options and plan their suicides, write notes, and address the pragmatics as though they were organizing a holiday in outer space. They usually believe not only that death will improve their condition, but also that it will remove a burden from the people who love them (in fact the opposite is usually true). The last group commit suicide through a reasonable logic. These people—because of physical illness, mental instability, or a change in life circumstance—do not wish to experience the painfulness of life and believe that the payoff they might receive in pleasure is insufficient to requite current pain. These people may or may not be accurate in their predictions of the future, but they are not deluded, and no amount of antidepressant medication or treatment will change their mind.

To be or not to be? There is no other subject about which so much has been written and about which so little has been said. Hamlet proposes that the decision may rest on that “undiscover’d country from whose bourn no traveler returns.” And yet men who do not fear the unknown, who gladly venture into territories of strange experience, do not so gladly leave this world of slings and arrows for a state of which nothing can be known, much can be feared, and all can be hoped. In fact, “conscience does make cowards of us all; and thus the native hue of resolution is sicklied o’er with the pale cast of thought.” This is the real question of being and not being: conscience here is consciousness, resisting annihilation not only through cowardice but also through some underlying will to exist, to seize control, to act as it is necessary to act. Moreover, the mind that recognizes itself cannot derecognize itself, and it is contrary to introspective life to destroy itself. The “pale cast of thought” is that within us that keeps us from suicide; those who kill themselves have perhaps felt not only despair, but also the momentary loss of self-consciousness. Even if the choice is simply between being and nothingness—if one believes that there is nothing at all beyond death and that the human spirit is no more than a temporary chemical arrangement—being cannot conceive of not being: it can conceive of the absence of experience but not of absence itself. If I think, I am. My own view when I am healthy is that there may be glory, peace, horror, or nothing on the other side of death, and as long as we don’t know, we should hedge our bets and make the most of the world we inhabit. “There is but one truly serious philosophical problem, and that is suicide,” Albert Camus wrote. Indeed, a large number of French people devoted their lives to this problem in the middle part of the twentieth century, taking up in the name of existentialism the questions religion had once sufficed to answer.

Schopenhauer unpacks the question. “Suicide may be regarded as an experiment,” he writes, “a question which man puts to Nature, trying to
force her to answer. The question is this: What change will death produce in man’s existence and in his insight into the nature of things? It is a clumsy experiment to make, for it involves the destruction of the very consciousness which puts the question and awaits its answer.” It is impossible to know the consequences of suicide until one has undertaken it. To travel to the other side of death on a return ticket is an attractive idea: I have often wanted to kill myself for a month. One shrinks from the apparent finality of death, from the irretrievability of suicide. Consciousness makes us human, and there seems to be general agreement that consciousness as we know it is unlikely to exist beyond death, that the curiosity we would satisfy will not exist by the time it is answered. When I have wished not to be alive and wondered what it would be like to be dead, I have also recognized that to be dead would defeat the wondering. It is that wondering that keeps one going: I could give up the externalities of my life, but not the puzzling.

Though brute instinct plays the lead part, the rationale for living is, in a secular society, extremely difficult. “That life is worth living is the most necessary of assumptions,” George Santayana wrote, “and were it not assumed, the most impossible of conclusions.” The many afflictions that assail us must be considered, but perhaps more urgent is the fact of mortality. Death is so alarming and its inevitability such a disappointment that some people feel they might as well get it done with. The idea of an ultimate nothingness seems to negate the value of a current somethingness. In fact, life denies suicide by obscuring, most of the time, the reality of one’s own mortality. If death is not proud, that is because it is so generally disregarded.

I do not believe that you have to be insane to kill yourself, though I think many insane people do kill themselves and that many other people kill themselves for insane reasons. It is obvious that the analysis of the suicidal personality has to be undertaken either retrospectively or after a failed suicide attempt. Freud himself said that “we have no adequate means of approaching” the problem of suicide. One must appreciate his deference to this subject; if psychoanalysis is the impossible profession, suicide is the impossible subject. Is it crazy to want to die? The question is ultimately a religious rather than a medical one, since it depends not only on what lies on the far side of death, but also on how highly we value life. Camus suggested that what is really crazy is the lengths to which most of us go to postpone inevitable death by a few decades. Is life only an absurd deferral of death? I believe that most people, on balance, experience more pain than pleasure in a lifetime, but we hunger for the pleasure and for the cumulative joy it breeds. Ironically, most of the religious faiths that posit eternal life have prohibitions
against suicide, prohibitions that prevent the fervent from leaping off cliffs to join the choirs of angels (though religions can celebrate giving up life for the cause, as in Christian martyrdoms or Islamic holy wars).

The power to commit suicide has been lauded by many men who cherished life, from Pliny, who said, “In all miseries of our earthly life, to be able to compass one’s own death is the best of God’s gifts to man”; to John Donne, who wrote in
Biathanatos
in 1621, “Whensoever any affliction assails me, methinks I have the keys of my prison in mine own hand and no remedy presents itself so soon to my heart as mine own sword”; to Camus. “It will generally be found,” Schopenhauer has declared, “that as soon as the terrors of life reach the point at which they outweigh the terrors of death, a man will put an end to his life.” I have myself experienced in depression a terror of life that was utterly overpowering, and at that time I was dangerously inured to the fear of dying. I believed, however, that my terror was temporary, and that mitigated it enough to make it bearable. Rational suicide in my view cannot be a present-tense operation; it must be contingent on an accurate assessment of the longer term. I am a believer in rational suicide, which responds to futility rather than to hopelessness. The problem is that it is frequently difficult to see which suicides are rational, and it is, I believe, better to save too many people than to let too many people go. Suicide is famously a permanent solution to an often temporary problem. The right to suicide should be a basic civil liberty: no one should be forced to live against his will. On the other hand, suicidality is often temporary, and vast legions of people are glad to have been pulled back from suicide attempts or constrained from making them. If I ever attempt suicide, I’d like someone to save me, unless I have reached a point at which I accurately believe that the amount of joy left in my life cannot exceed the amount of sorrow or pain.

Thomas Szasz, an influential critic of the mental health establishment who has favored limiting the power of psychiatrists, says, “Suicide is a fundamental human right. This does not mean that it is desirable. It only means that society does not have the moral right to interfere, by force, with a person’s decision to commit this act.” Szasz believes that by intervening forcibly with the suicidal, one deprives them of the legitimacy of their selves and actions. “The result is a far-reaching infantilization and dehumanization of the suicidal person.” A Harvard study gave doctors edited case histories of suicides and asked them for diagnoses; while the doctors diagnosed mental illness in only 22 percent of the group if they were not told that the patients had committed suicide, the figure was 90 percent when the suicide was included in the patient profile. Clearly, suicidality creates a smooth diagnosis, and it is likely that some degree of infantilization—or at least paternalism—occurs. Szasz’s position has
some basis in reality, but making clinical decisions on the basis of it can be extremely dangerous. The psychologist Edwin Shneidman, who began the suicide prevention movement, represents the other extreme. For him, self-murder is a mad act. “There is at least a touch of insanity in every suicide in the sense that, in suicide, there is some disconnection between thought and feelings,” he writes. “This results in an inability to label emotions, or to differentiate them into more subtle shades of meaning, and communicate them to others. It is this abnormal ‘split’ between what we think and what we feel. There lies the illusion of control; there lies madness.” This tautological view gives a basis for depriving people of their right to suicide. “Suicide is not a ‘right,’ ” Shneidman has written in pungent opposition to Szasz, “any more than is the ‘right to belch.’ If the individual feels forced to do it, he will do it.” One does, it seems worth noting, have control over belching some of the time, and one does restrain oneself as much as possible in public situations, in deference to others.

Suicide is astonishingly common and is disguised and trumped up more even than depression. It is, indeed, a vast public health crisis that makes us so uncomfortable that we divert our eyes from it. Every seventeen minutes, someone in the United States commits suicide. Suicide ranks number three among causes of death for Americans under the age of twenty-one, and it is number two for college students. In 1995 (for example), more young people died of suicide than of AIDS, cancer, stroke, pneumonia, influenza, birth defects, and heart disease combined. From 1987 to 1996, more men under the age of thirty-five died of suicide than of AIDS. Nearly half a million Americans are taken to hospitals every year because of suicide attempts. Suicide was, according to the World Health Organization, responsible for almost 2 percent of deaths worldwide in 1998, which puts it ahead of war and way ahead of homicide. And the rate of suicide is climbing steadily. One recent study conducted in Sweden showed the likelihood that a young man in the study’s catchment area would commit suicide has increased by 260 percent since the 1950s. Half of those with manic-depression will make a suicide attempt; one in five people with major depression will do the same. Someone in a first depressive episode is particularly likely to attempt suicide; a person who has lived through a few cycles has in general learned to live through cycles. Previous attempts at suicide are the strongest factor in predicting suicide: about a third of the people who kill themselves have tried before; 1 percent of those attempting suicide will complete a suicide within a year; 10 percent will kill themselves within ten years. There are approximately sixteen suicide attempts to every completed suicide.

I have seen in a single document both the assertion that depressed people are five hundred times as likely to commit suicide as their nondepressed
counterparts and the statistic that depressed patients have a suicide rate twenty-five times the societal norm. I have read, elsewhere, that depression increases the likelihood of suicide twofold. Who knows? Such rates depend in large part on how one defines that slippery demon depression. For what appear to be public health reasons, the National Institute of Mental Health grandly if unscientifically averred for a long time that “almost all people who kill themselves have a diagnosable mental or substance abuse disorder”; they recently downgraded the “almost all” to “90 percent.” This notion helps people who have made unsuccessful suicide attempts, and those left grieved by the suicide of someone to whom they were close, to expel some of the guilt that might otherwise fetter them. Comforting though this is, and useful though it may be in drawing attention to the high level of illness-associated suicide, it is a gross exaggeration, not corroborated by anyone I’ve met who has treated suicidal patients.