June 2007, Volume 57, Issue 6

Opinion and Debate

The Suicide Note: What can be done in the light of its implications?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada )

The problem with suicide in Pakistan has reached an alarming proportion. Much has been reported in print media and some articles are available in local and international literature originating from the country. The conduction of a thorough systematic study has always remained a problem because of multiple reasons including reluctance to report such an incident. A very interesting and thought provoking aspect of suicide is the 'suicide note' that has come under discussion. It is a message left by those who resort to bring an end to their life. Generally, many suicide attempters do not leave a note but only less than 10% would do so.1 There are many reasons given for writing up of suicide notes like: confessing about a deed that resulted in guilt feelings, to give reasons for suicide, to instruct the survivors about disposal of property or to apologize. Those who do not leave a note are said to have done so because they would have nothing to say, or were uncomfortable with written language, their attempt was impulsive; they had difficulty with expression or because of illiteracy.1 Anecdotal evidence from Pakistan reveals that the contents of such notes were seeking of apology for the act as they were unable to cope with the misery any longer, were unable to express their feeling when alive, had great disappointment with people about whom they cared a lot, elderly people who did not want to be a burden and failure to achieve success in a goal, may it be a job, exam or a love affair. A death poem has also been reported in literature narrating the miserable life cycle culminating in death due to suicide.1 According to a Mexican study2, low level of education was associated with fewer suicide notes and that suicide in Mexico is associated with numerous interpersonal problems. In a study3 from India, it was revealed that males wrote more suicide notes as compared to females and there was association with a number of psychiatric and psychological factors. Some authors4 have claimed no statistically significant difference among suicide note leavers versus non-leavers in terms of sex, age, family status, psychiatric care, motive or method. Research5 shows that elderly suicide note leavers were more likely to be unknown to the psychiatric services and to have used a non-violent method for suicide. Those elderly people who died by more violent means appeared less likely to have left a suicide note.  It is also said that non-leavers of suicide notes had tendencies to commit suicide for reasons of physical illness, psychiatric disorders or a previous history of mental illness.6 Research7 on themes detected by examination of 42 suicide notes from Northern Ireland revealed that 'apology/shame' (74%), 'love for those left behind' (60%), 'life too much to bear' (48%), hopelessness (40%), 'burden to others' (40%) etc. A study from Montreal8 in which contents of suicide notes among adolescents were examined revealed that older adolescents were concrete, left specific instructions, did not address the note, did not give a reason for the act and tended to choose intoxication as a method.  Suicide notes are important source of forensic data that are used in courtrooms quite often.9 Suicide notes are considered markers of the severity of attempt and provide good insight into the psychodynamics and frame of mind of the individual but the attempt of non-note leavers should by no means be less serious.10 Suicide does not come to surface in Pakistan with its real magnitude because of legal complexities and stigma. Attempts are being made by researchers to probe deeply into this issue. Unofficial reports about examination of suicide notes draw attention to serious issues prevailing in the society. Notes written by adult males were expression of frustrations of unemployment, poverty, high expectations from family and harassment by law enforcing agencies. Such issues are widely visible and a number of people suffer from it and finding ultimate solace in getting rid of life that was very precious. The cultural connotations cannot be ignored in terms of prohibition of expression by rural women who are subjected to forced marriages, bonded labour and educational deprivation. Many of such women expressed their fear and constant agony while surviving in an atmosphere of terror. In the present era, people are exposed to undesirable circumstances and have developed a mass feeling of helplessness and hopelessness. A large number of population does not seek treatment for mental disorders like depression which is the commonest cause and if unattended may result in suicide which is preventable. Such suicide notes can be a source of great information and are instrumental in developing a great insight into gravity of the problem. Much can be done to address this issue. Expression of death wish should not be ignored at all and careful attention should be given.11 The family members can play a big role in prevention of suicide by attending to these expressions at the initial level. The family practitioners can either treat the condition or refer to a mental health professional or conduct a counseling session in collaboration with the family members. The family members should be educated in understanding the emotions and need for expression of problems by the other family members. Cohesion among family members is important and elders can play an effective role in this matter. Psychiatrists should tailor their treatment appropriately and devise problem solving cognitive therapy techniques along with other supportive psychotherapies that would prove helpful in prevention of suicide.7 Suicide notes many a times indicate a perpetual problem leading to the act. It is the responsibility of the society to make collective efforts in eliminating evil social issues that plunge a large number of people into the darkness of hopelessness, depression and eventual suicide.   There are vistas for research in addressing the suicide notes as they can be a rich source of information about mental health morbidity, social stressors, forensic issues and about etiological factors leading to suicide. The ground is fertile for scientists/health professionals to explore this aspect that will go a long way in understanding the dynamics of this problem and will help in devising strategies leading to prevention, early detection, prompt treatment and rehabilitation for mental illness.  The dilemma lies in the fact that research on this aspect has inherent difficulty for multiple reasons like: low number of people leaving a suicide note, bottlenecks in legal system, identification of an appropriate research instrument and retrieval of such notes from the relatives of the deceased. Even if a successful attempt is conducted and the research findings are widely available, will it affect the health policy makers in initiating a comprehensive prevention plan? Will our social system improve by extending solace and sympathetic listening to a number of such people who find it difficult to ventilate their miserable feelings and who have no other outlet but to bring an end to their own lives while leaving a 'note' with the posthumous hope of someone coming to help those who are still surviving under the umbrella of hopelessness and helplessness.  One wonders whether there will ever be a place like that of 'Hyde Park' in Pakistan where one can express feelings with freedom and with the aim of ventilation?

References

1. The suicide note by Wikipedia at http://en.wikipedia.org/wiki/Suicide_note date accessed: 27/3/2007.
2. Chavez-Hernandez AM, Paramo D, Leenaars AA, Leenaars L. Suicide notes in Mexico: what do they tell us? Suicide Life Threat Behav 2006; 36: 709-15.
3. Girdhar S, Leenaars AA, Dogra TD, Leenaars L, Kumar G. Suicide notes in India: what do they tell us? Arch Suicide Res 2004; 8:179-85.
4. Eisenwort B, Berzlanovich A, Willinger U, Eisenwort G, Lindorfer S, Sonneck G. Suicide notes and their importance to suicide research: The representativeness of suicide note writers. Nervenarzt 2006; 77: 1355-62.
5. Salib E, Cawley S, Healy R. The significance of suicide notes in the elderly. Aging Ment Health 2002; 6:186-90.
6. Kuwabara H, Shioiri T, Nishimura A, Abe R, Nushida H, Ueno Y, et al. Differences in characteristics between suicide victims who left notes or not. J Affect Disord 2006; 94:145-9.
7. Foster T. Suicide note themes and suicide prevention. Int J Psychiatry Med 2003; 33: 323-31.
8. Posener JA, LaHaye A, Cheifetz PN. Suicide notes in adolescence. Can J Psychiatry 1989; 34:171-6.
9. Leenaars AA. Suicide notes in the courtroom. J Clin Forensic Med 1999; 6: 39-48.
10. Salib E, El-Nimr G, Yacoub M. Their last words: a review of suicide notes in the elderly. Med Sci Law 2002; 42: 334-8.
11. Gadit AA. Death wish or suicidal ideation: Implications for management. J Pak Med Assoc 2007,57:156-7.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: