Suicide Hotspot: “A Long Way Down”

A Hornby’s novel, published in 2005. 

On the night of the 31th December four people, apparently with nothing in common, find themselves involved in a strange and unusual adventure. They met for the first time on the top of “The House of Suicide”, a skyscraper in London, where they went up with the intention of committing suicide. The protagonists are: Maureen, a lonely woman taking care of a seriously disabled son named Matt; Martin, a journalist who spent a period in jail after having a sexual intercourse with a 15 years old girl, and, after this fact, lost his family, friends and job; Jess, a problematic adolescent girl, with a tragic history in her past and JJ, an American pizza-boy, who was a musician in his country, but his band dissolved and he broke up with his girlfriend. All these people have different tragic past  stories and live in difficult conditions, but, when they start talking on the roof of the skyscraper and sharing their problems, they decide not to commit suicide in that moment. They start a strange friendship, and, in an unusual way, they help each other, talking with honesty, frankness and true empathy. They start to meet periodically, and everytime they postpone the decision about suicide, sharing and comparing their life problems. On the 14th February they decide to go up on the skyscraper “House of suicide”, where they find a man. They try to talk to him, but he commits suicide in front of their eyes. After that, they understand they don’t really want to end their life, and, likewise, they need to stay together, and through their particular friendship, they start to look in a different way to their life and start giving themselves a chance. They go on with a new point of view: although life is not always beautiful and easy, they try to face it step by step, and continue postponing the decision of suicide, never saying “I’ll never do that”, but just waiting for taking this decision, and, in this way, they continue with their life and friendship.

To know more about suicide hotspot visit our post about it!

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Suicide Hotspot

The hotspot is also known as “iconic site” or “suicide magnet”. It is “A specific, usually public, site which is frequently used as a location for suicide and which provides either means or opportunity for suicide”. It is almost always a jumping site; examples are the Golden Gate Bridge, the Eiffel Tower, and Niagara Falls” (National Institute for Mental Health In England, 2006). They also receive a disproportionate amount of media attention.

The “Guidance on action to be taken at suicide hotspots” (2006), developed by the National Institute for Mental Health in England, on the Suicide Prevention Resource Center Website, qualifies the suicide hotspot as follow:

“The term ‘suicide hotspot’ has two possible meanings. It is frequently used to refer to both: a) a geographical area with a relatively high rate of suicide among its resident population (e.g. a town, borough, county or country), and b) a specific, usually public, site which is frequently used as a location for suicide and which provides either means or opportunity for suicide (e.g. a particular bridge from which individuals frequently jump to their deaths)”.

The Guidance reports examples of prevention methods that may be applied to hotspots with proven efficacy: physical barriers, telephone hotlines also encouraged by placing telephones nearby the hotspot, increasing the possibility of intervention by a third party, suicide patrols or trained staff of non-health agencies working at or near hotspots, finally,  paying attention to media reporting (e.g. media guideline).

In 2013 BMC Public Health published a systematic review about suicide hotspots that highlighted quite the same methods to prevent suicide in these areas as those indicated in the Guidance (1). In the same year a meta analysis about the effectiveness of structural interventions at suicide hotspots concluded that structural interventions at ‘hotspots’ avert suicides in these sites: “Some increases in suicide are evident at neighbouring sites, but there is an overall gain in terms of a reduction in all suicides by jumping” (2).

Developing suicide prevention strategies in these places requires complex questions of ownership, responsibility and resources.

On the Center for suicide prevention website there is an interesting editorial about the topic: “Jumping and Suicide Prevention”. It talks about suicide by jumping from heights and arguments for and against barriers.

It is known that barriers and other prevention methods may not stop an individual that wants to commit suicide, but multiple efforts should be performed to prevent the event, because, as reported in the editorial:

“A barrier or another prevention measure should not be up for debate. If suicides have occurred previously in the location… it is worth the expense.
Even one suicide is too many”.

  1. Interventions to reduce suicides at suicide hotspots: a systematic review
  2. The effectiveness of structural interventions at suicide hotspots: a meta-analysis.
  3. “Jumping” and Suicide Prevention

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Thirteen reasons why: new episodes, debate still ongoing

Since 18th May 2018, new episodes of the TV series “Thirteen reasons why” are available on Netflix. Anna Baker’s story has divided the scientific community about suicide and how this difficult topic should be discussed by and through the media.

Different scientific papers have been published about this topic. On “Health communication” it has recently been published the article “#13ReasonsWhy Health Professionals and Educators are Tweeting: A Systematic Analysis of Uses and Perceptions of Show Content and Learning Outcomes” that analyses more than 700 health professionals’ and educators’ tweets about the Netflix show. In October 2017, JAMA Internal Medicine published the editorial “A Call for Social Responsibility and Suicide Risk Screening, Prevention, and Early Intervention Following the Release of the Netflix Series 13 Reasons Why” linked to the research letter “Internet Searches for Suicide Following the Release of 13 Reasons Why”. The Authors of the letter reported that suicide-related internet searches increased following the release of the series 13ReasonsWhy, even though it’s impossible to discriminate whether  the internet searches had been performed by scientists, teachers or people contemplating suicide.

On the American Journal of Maternal/Child Nursing, the article “13 Reasons Why: A Trigger for Teen Suicide?” discusses the controversy raised by the Netflix series and expressed by school officials, healthcare providers, and parents. This paper, as many dissemination websites, such as Huffington Post and Washington Post, suggests that the series may romanticize suicide and eventually lead to possible negative effects. On the other hand, hypotheses have been suggested that the series may help specialists and people from the community to discuss about the difficult topic of teenagers’ suicide.

In any case, certainly the series fostered the debate about suicide.

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Image from Pixabay

Bulgakov’s Morphine: substance use disorders and suicide

Morphine is a story written by Michail Bulgakov, published for the first time in 1927 on the magazine “The Medical Worker”.

The book, written in form of diary, is focused on the personal history of young doctor Polijakov, describing feelings and consequences of substance use disorder, until the extreme one: suicide. Polijakov has his first contact with morphine during a crisis of abdominal pain. From this moment, Polijakov’s life falls into a spiral of decadence and addiction: recruitment and research of the substance become the young doctor’s only concerns, and as a consequence he eventually neglects his work and personal relationships. Moreover, the abuse of morphine causes him physical consumption and psychiatric symptoms, with the onset of hallucinations and distress which lead the young doctor into a voluntary hospitalization in a detox clinic. This attempt fails: he escapes from the clinic and restarts abusing. Exasperated by his situation, for which he sees no way out, Polijakov writes a letter to ask for help to a university classmate, but after sending the letter, hopeless and full of remorse, he impulsively decides to take his own life; his diary is then delivered to the colleague to whom he had asked for help, who decides to publish and share Polijakov’s memories (to know more about the topic read our new reading suggestion at this link).

This tale describes drug addiction from the point of view of an addicted, depicting young doctor’s thoughts. We sew the first contact with the substance, the excuses that Polijakov gives himself to continue in the abuse of morphine, the intense craving and, when he becomes conscious of his problem and the sense of fail and hopelessness related to the awareness that he is not able to stop morphine abuse; the shame for his condition finally leads him to the extreme gesture. This book also contains many autobiographical references; the author himself has suffered from morphine addiction during his life.

We choose this book as reading suggestion for this month because substance use disorder is one of risk factors for suicide; moreover, recent review highlights the frequency of self-harm and suicide between medical doctors. Perhaps not everyone knows that Michail Bulgakov, besides being a famous writer, was a medical doctor. After graduation he worked as a physician at the Kiev Military Hospital and then, during the First World War, as a volunteer in the Red Cross to the front. Then he worked as a surgeon and was eventually appointed provincial physician.

To know more about suicide among people with substance use disorders contact us for our Flyers about the argument (to know more visit our page about Flyers).

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  • “Morphine” text by Mikhail Bulgakov
  • Wikipedia:
  • Psychosocial job stressors and suicidality: a meta-analysis and systematic review. Milner A, Witt K, LaMontagne AD, Niedhammer I, Occup Environ Med. 2018 Apr;75(4):245-253. doi: 10.1136/oemed-2017-104531. Epub 2017 Aug 29.

Image from Pixabay

Robin Williams’ death and copycat suicides

In a previous article we reported about celebrities, as Chris Cornell and Chester Bennington, who committed suicide (Click HERE to read the article). It is widely acknowledged that a celebrity suicide may influence population health, in particular suicides rate may increase in the next weeks due to copycat and Werther effect (Click HERE to know more about Werther Effect), and this may have a varying impact in different populations and cultures.

The role of media communicating the news is very important: the World Health Organization recently published an update in the guidelines “Preventing suicide: a resource for media professionals”, where there is a specific section named “Apply particular caution when reporting celebrity suicides” (Click HERE for the Guidelines).

Many articles about the topic were published after Robin Williams’ death, occurred in 2014: this is a good example in order to explain the topic. Robin Williams was a famous actor, with a 35-year career on screen, playing lead roles in different famous films (es: Dead Poets Society, Mrs. Doubtfire…). The day Williams died, the National Suicide Prevention Lifeline received the highest number phone calls ever.

A recent open access study published on PLOS One investigates suicides following the death of the actor Robin Williams: using a time-series analysis, researchers reported that suicides observed exceeded expected ones; this was observed across gender and age groups.  

LINK to articleIncrease in suicides the months after the death of Robin Williams in the US

Moreover, on Health Communication Young it was published an article about a survey on how his death influenced searches for information concerning depression, suicide, and mental health. They found, for example, that respondents who sought information about the suicide reported changes in their thoughts about suicide, most often dealing with the difficulty in spotting warning signs and the idea that “it can happen to anyone.”

LINK to the articleTweeting celebrity suicides: Users’ reaction to prominent suicide deaths on Twitter and subsequent increases in actual suicides.

Finally, the relationships between guidelines and news about suicide were assessed in a study performed at the Mental Health University Institute in Quebec by Creed and Whitley. In Canada guidelines and best practice have been recently published to help journalists writing about mental health and suicide. Creed and Whitley tried to relate these norms to the pieces written about Robin Williams’ suicide from major Canadian newspapers: they observed that articles generally followed the evidence-based guidelines when reporting about Williams’ suicide.

LINK to the article: Assessing Fidelity to Suicide Reporting Guidelines in Canadian News Media: The Death of Robin Williams

In conclusion, as described in the WHO guidelines, celebrity suicides are particularly likely to induce copycat suicides: “the effect of a report about a suicide on subsequent suicides is greater when the person described in the story is a celebrity and is held in high regard by the reader or viewer. Particular subgroups in the population (such as young people, people suffering from mental illness, persons with a history of suicidal behaviour or those bereaved by suicide) are particularly vulnerable to engaging in imitative suicidal behaviour”.

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Image from Pixabay

TV Series & Suicide: The End Of The F****ing World & 13 Reasons Why

From October 2017 on Netflix is available a new series named “The End Of The F****ing World”. The story is about  two teens, Alyssa and James,  who run away from home and start a journey together, full of serious difficulties, in which they learn something about themselves and each other.  

Exactly like “13 Reasons Why”, another Netflix series, the theme of suicide is the key of the story. In “The End Of The F****ing World”, many flashbacks help the viewer to understand James’s family history. The young boy is grieving the devastating loss of his mother and this influences many of his behaviors.

In “The End Of The F****ing World” and  in “13 Reasons Why” we can find how suicidal behaviors influence other people’s life: suicide is a complex tragedy without one singular cause but may affect many people’s life, “the survivors” (to know more about the topic Survivor you can also read our article: “Chris Cornell, Chester Bennington ans Survivors of Suicide Loss“). 

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Image from Pixabay

Echoes of the TV series “13 reasons why” release: an ongoing scientific debate.

13 Reasons Why is an American web television series, based on the 2007 novel by Jay Asher. The story revolves around an high school student and his friend, Hannah Baker, a girl who committed suicide after suffering a series of demoralizing circumstances brought on by selected individuals at her school. A box of cassettes recorded by the main character details thirteen reasons why she ended her life.

Ayers at al. published on July 31, 2017 a Research Letter on JAMA, describing his study on how internet searches for suicides changed, both in and content, after the series’ release. Using Google Trends the Authors applied a “quasi-experimental approach”, comparing internet search volumes after the premiere of the TV series, with expected search volumes if the series had never been released. In the end, it is unclear whether any internet query preceded an actual self-harm attempt. Results and conclusions of their analyses suggest that 13 Reasons Why, in its present form, may have both increased suicide awareness while unintentionally increasing suicidal ideation.

It is widely acknowledge in the literature that the negative effects of TV shows, such as the one in question, could be avoided following the WHO’s media guidelines for preventing suicide, which suggest to remove explicit scenes and to include suicide hotline numbers in each episode. On July 31, in an Editorial published on JAMA Editorial, Kimberly H. et al. state that, considering the strong audience response to the mentioned TV series, it is probable that others may be encouraged to produce similar shows. Furthermore new patterns of utilization of TV series such as “binge watching” increase the emotional impact and immersion into the story. This makes more urgent the application of preventive screening strategies.

Ungar et al. (2017) argued that international guidance on suicide and media should be strenghtned, implemented and enforced; proposing a “human centered design”, encouraging viewers to seek help for mental health problems supported by their study evidence that the “edutainment” design works for prevention.

On the contrary, Scalvini and Rigamonti published a Letter on the BMJ in October 2017, affirming that fictions such as 13 Reasons why may be a starting point for inspiring dialogue between adolescents and their main role model, parents, educators and therapists, and not delegate educational roles to the media which should not be censored. These Authors suggest that such shows could be used to demand the  government investing more in mental health services for young people.

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The Origin of the Werther Effect

Media coverage of suicide is now well known to have a significant influence on suicide epidemiology. This influence is supposed to result from two opposite effects, the Werther and the Papageno effect (to know more about Papageno, click here).

The “Werther effect” refers to the increase of suicide rates following the publication of a suicide story, just as it happened after the publication of The Sorrows of Young Werther (original title Die Leiden des jungen Werthers) by Johann Wolfgang von Goethe, in 1774. The publication of The Sorrows of Young Werther had several effects: at the individual level, it turned 24-years old Goethe into a celebrated author. From a socio-cultural standpoint, it started the phenomenon known as the “Werther Fever”. The Werther Fever encompassed harmless behaviors, such as having young European men adopting Werther’s clothing style, as well as life-threatening ones, leading to some of the first known examples of copycat suicide.

The Sorrows of Young Werther is an autobiographic novel, and is considered the most important manifesto of the Sturm und Drang, a literary movement developed in Germany between 1770 and 1785, which preannouced and influenced the later Romantic movement. The Sturm und Drang movement included eminent authors such as Schiller and Klinger, and had as main topic the exaltation of the primordial and authentic human being spirit, ruled by the restless search for an absolute freedom, and intolerant to any constriction. These characteristics were developed by the young German writers in contrast to the French Neoclassicism and its rules, which were considered retrictive and mortifying for the Artist.

In the context of this cultural movement, Goethe developed the theme of the human incapacity to control passions and of the consequent social discomfort, bringing to life one of the most famous characters of world literature: Young Werther.

The plot is well known: the novel, throughout the letters collected by his friend Wilhelm and the fake Editor’s notes, narrates about Werther, a young artist of passionate and sensitive temperament. He moves to the fictional village of Walheim in order to arrange some business and dedicate himself to Classical studies. One night, during a party, he is introduced to a young beautiful woman, Charlotte, who is engaged to Albert, eleven year her senior. Despite knowing about Charlotte’s condition, Werther falls in love with her, cultivating a close and suffering friendship. His sorrow eventually becomes so unbearable that he is forced to leave Walheim for Weimar at an embassy. But for such a spontaneous and passionate personality, as Werther’s, it is impossible to fit the sterile and cold environment typical of the high society classes, therefore he decides to go back home. However, also there the young man can’t find peace: he is assaulted by nostalgia and memories of Walheim. The sudden news of Albert and Charlotte’s marriage further destabilizes him. Disheartened and growing more and more sullen everyday, Werther decides to return to Walheim, but this time his passion for the young woman is no longer concealed and becomes so clear that Charlotte herself, despite her attachement, asks him to be less demanding. One night, while Albert is absent, Werther impulsively kisses Charlotte, misunderstanding her feelings.  She, out of pity for her friend, and respecting her husband, decides that Werther must not visit her so frequently. This event is devastating for him, so after composing a farewell letter to be found after his death, he writes to Albert asking for his two guns, on the pretext that he is going “on a journey”. Werther then shoots himself in the head, but does not die until twelve hours later.

The disruptive effect of this work in late 17th century literature is due to its main character tragic end. This novel outlined a new character: the sensitive and passionate Hero. A man governed by instincts, who prefers indulging to his emotions rather than repressing them, a man who, because of this, experiences difficulties in his attempt of fitting into society. Werther loves nature, admires childhood spontaneity, and lazing into an ideal, unattainable and impossible love. In the novel, Werther’s character is counterposed to his alter-ego Albert: the bourgeois man, strong, rational, positive, but limited.

This two characters compare themselves one to the other also debating about suicide. In Albert’s opinion suicide is a sign of weakness and insanity; on the other hand, the Hero of Passions thinks that suicide discloses the absolute catharsis, a demonstration of the heroic courage proper of great men. Suicide is described by Werther as a proof of the strength of human being, who, oppressed by life unhappiness, is eventually able to perform a last titanic action, just like people rising up against a tyrant; like the man who succeeds in saving his belongings from his burning house; or like the warrior who is left alone on the battle field, but still fights against many enemies.

It seems like the sensitive Werther is trying to get the chance to demonstrate his belonging to this heroic slice of humanity. He was informed about Charlotte’s engagement even before knowing her, but still conscious of the impossibility of their love, chooses to indulge in his passion. The whole novel describes Werther’s descent into the abyss of depression, fostered by a feeling he can not avoid. Goethe tells his readers the already written destiny of his Hero, who has no other chance but the definitive escape from inevitable pain of his sensitive soul.

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Thanks to Matteo Savin

Chris Cornell, Chester Bennington and Survivors of Suicide Loss

Chris Cornell was an American musician, singer, and songwriter, ex frontman of the Audioslave and Soundgarden; Wikipedia says that he is considered one of the chief architects of the 1990s grunge movement. He was found dead in his Detroit hotel room on May 18, 2017 after performing at a concert the night before; the cause of death was determined to be suicide by hanging and “drugs did not contribute” to the cause of death: only prescription medications were found in Cornell’s system.
Cornell publicly talked about his struggle with depression, isolation and suicidal thoughts several times throughout his life

Members of his family and numerous fans of the artist were impressed by her premature death;

Associated Press writes that the representative of the artist Brian Bumbery said that his death was “sudden and unexpected”. Cornell’s wife said, “When we spoke after the show, I noticed he was slurring his words; he was different. When he told me he may have taken an extra Ativan or two, I contacted security and asked that they check on him.”  
Touching is the letter written by his wife: “I’m sorry, my sweet love, that I did not see what happened to you that night,” she wrote. “I’m sorry you were alone, and I know that was not you, my sweet Christopher. Your children know that too, so you can rest in peace.”  
Several tributes and phrases have been dedicated to Cornell around the world as a sign of contempt for a friend, colleague and teacher.

The relationships between Cornell’s suicide and those of other rock singers is spontaneous and also with the dead of his close friend and colleague Chester Bennington, lead singer of Linkin Park, that two months after Cornell’s death, on July 20, the day that would have been Cornell’s 53rd birthday, hanged himself. Bennington was a close friend of Cornell’s: the two had performed together, Bennington was godfather to Cornell’s son Christopher, and  at Cornell’s funeral he sang Leonard Cohen’s “Hallelujah”. Bennington’s family and bandmates said he had taken Cornell’s death very hard: “I can’t imagine a world without you in it,” he had written on Instagram upon hearing the news.

There are many reasons why someone commit suicide, but today we know that death by suicide devastates those left behind. “More than half of Americans personally know someone who has died by suicide, and we are all affected when a celebrity to whom we feel connected ends their life,” said Julie Cerel the President of American Association of Suicidology.
We call them “Survivors of Suicide Loss”, who are those who have lost a friend, a family member or someone they love to suicide. They are effectively at elevated risk for depression and suicide, and this is particularly true in important dates of those lost to suicide. Death by suicide stuns with soul-crushing surprise, leaving family and friends not only grieving the unexpected death, but confused and lost by this haunting loss. The underlying structure of grief for survivors of suicide loss appears complicated. It is further complicated by the societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue and ultimately society affixes blame for the loss on the survivors. We can say that survivors should not expect that their lives will return to their prior state, they should adjust their life without their loved one.
Sometimes the individual or societal stigma introduces a unique stress on the bereavement process that in some cases requires clinical intervention.

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