Night Falls Fast

Jamison, Kay Redfield. Night Falls Fast: Understanding Suicide. New York: Vintage Books, 2000.

Suicide is a particularly awful way to die: the mental suffering leading up to it is usually prolonged, intense, and unpalliated. There is no morphine equivalent to ease the acute pain, and death is not uncommonly violent and grisly. The suffering of the suicidal is private and inexpressible, leaving family members, friends, and colleagues to deal with an almost unfathomable kind of loss as well as guilt. Suicide carries in its aftermath a level of confusion and devastation that is, for the most part, beyond description. (p. 24)

In Night Falls Fast, Kay Redfield Jamison delves into a discussion of suicide with precision and aplomb. Her ultimate goal is to shine light into the darkness of suicide in an effort to gain a better understanding of the act. She examines a variety of facets of suicide including its history, its connotations, its biological underpinnings, as well as its psychological implications. This is a book that helps us to understand the suicidal mind and to recognize and come to aid of those at risk. She is a firm believer that suicide is preventable and her arguments are compelling.

Jamison is a prominent professor of psychiatry at Johns Hopkins University and the author of An Unquiet Mind: A Memoir of Moods and Madness and Touched With Fire: Manic-Depressive Illness and the Artistic Temperament. She is a renowned authority on mood disorders and suicide. Jamison begins the book with the painful story of her own suicide attempt. Like many who have bipolar disorder, Jamison knows suicide in an intimate way. When she was twenty-eight, after a damaging mania followed by a prolonged depression, Jamison took a massive overdose of lithium:

It was simply an end of what I could bear, the last afternoon of having to imagine waking up the next morning only to start all over again with a thick mind and black imaginings. It was the final outcome of a bad disease, a disease it seemed to me I would never get the better of. No amount of love from or for other people—and there was a lot—could help. No advantage of a caring family and fabulous job was enough to overcome the pain and hopelessness I felt; no passionate or romantic love, however strong, could make a difference. Nothing alive and warm could make its way in through my carapace. I knew my life to be a shambles, and I believed—incontestably—that my family, friends, and patients would be better off without me. There wasn’t much of me left anymore, anyway, and I thought my death would free up the wasted energies and well-meant efforts that were being wasted on my behalf. (p. 291)

Jamison was lucky: she survived. Following the attempt on her life, she turned her attention and scholarly skills to understanding what had happened to her.

Jamison emphasizes the highly disproportionate suicide rates among those suffering from the major mental and mood disorders of depression, bipolar disorder, and schizophrenia. These psychiatric conditions are by far the most commonly associated with suicide. The co-occurence of alcohol abuse and chemical dependency are frequent concomitants of suicidality as well and increase one’s risk for taking their life. Many neurotransmitters, such as serotonin, and hormones are critical to the regulation of mood and to the activation of the many behaviors such as impulsivity, aggression, and violence that are implicated in suicide and suicide attempts.

Jamison’s vigorous program for suicide prevention centers on prescription drugs that modulate levels of neurotransmitters. She emphasizes the underdiagnosis of depression and underutilization of antidepressants to treat severe depression and suicidal ideation. This is in opposition to reports that antidepressants are being handed out like candy by American physicians. While she does make room for the psychological and social factors that often precipitate the final decision to act on suicidal impulses, she makes it clear that she will not tolerate any dissent that suicidal depression is inherently biological and human behavior in general and mental health in particular are primarily determined by our genetic makeup and the chemicals in our brains:

Philosophical views and assumptions about the causation of suicide, while strongly held and necessarily and importantly debated, are not sufficient to disregard the massive and credible medical, psychological, and scientific research literature about suicide. Ignoring the biological and psychopathological causes and treatments of suicidal behavior is clinically and ethically indefensible. (p. 255)

Jamison is confident that the development of forms of biological analysis and neuroimaging may someday allow scientists to detect neurochemical and anatomical changes in the brain associated with an increased risk of suicide. And while she does not dismiss the value of psychotherapy in treating depression and preventing suicide, but believes that self-reflection is secondary to medical intervention:

The complexity of the suicidal mind and brain demands for its care a complexity of clinical thought and treatment. Psychotherapy alone, if used without addressing or treating the underlying psychopathology or biological vulnerabilities, is generally unlikely to prevent profoundly suicidal individuals from killing themselves. The ability to diagnose psychopathology accurately and to refer patients to colleagues for medication when necessary is a nonnegotiable fundamental of good clinical practice. Not to do this is malpractice. (p. 253)

Jamison’s persuasive use of statistics to demonstrate that suicide is a public health crisis makes it clear to the reader that suicide is a topic, as uncomfortable as it is, that needs our immediate attention. Even though her statistics are dated, the current numbers tell the same horrifying tale. It is a societal illusion that suicide is rare. In the United States, a person commits suicide every thirteen minutes. Suicide is the third leading cause of death among persons aged 10-14 years, the forth among persons aged 35-44 years, and the fifth among persons aged 45-55 years. Among high school students, 17% of students seriously considered attempting suicide in the previous year and 13.6% of students went so far as to make a plan about how they would attempt suicide.[ref]Suicide Facts at a Glance 2015. Centers for Disease Control and Prevention. http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.PDF[/ref]

Part of the strength of this book is the quality of Jamison’s writing. She writes with gravitas and immediacy. She excels at articulating the desperate pain of a person contemplating suicide and their often inability to think themselves out of it. She combines poetry, diaries of suicide, summaries of research studies, and her own experience. Her talent for synthesis and prose cannot be overstated. The result is a very informative book that reads like excellent literature.

While Jamison does a fantastic job in exploring the etiology of suicidal intent, the treatment of a suicidal mind, the prevention of suicide, and the portrayal of suicide in the media, I am disappointed that she did not investigate the ethics of suicide. There is a fascinating and disturbing report of a young Dutch woman who had been sexually abused and suffered from depression and other severe mental illnesses for more than a decade who recently ended her life by assisted suicide after psychiatrists deemed her condition incurable. In recent years, there has been a marked increase in the number of individuals in the Netherlands who have chosen to end their lives due to mental illness. Should people with a non-terminal illness be helped to die? Does a severely mentally ill person who wishes to escape prolonged suffering lack the capacity to make such a life-and-death decision?

Jamison notes the media’s role in potentially increasing suicide attempts. Many stories concerning a young person committing suicide are deemed newsworthy. It is known that news coverage of a suicidal event tends to heighten the public’s preoccupation with suicide. Sensationalizing suicide is also thought to be associated with a contagion effect. One wonders if suicide is indeed contagious as Jamison seems to suggest, is not her book itself a potential source of infection? Is it possible that someone who is thinking about suicide may find this text triggering? Or is the opposite true in that this book may symbolize hope in a person who is severely depressed in providing solace that they are not alone?

Lastly, is there a danger in placing nearly all of one’s faith in biological explanations of human behavior? While I agree that there is an indisputable link between biology and depression, it could be argued that Jamison endows the clinical research into prescription drugs and medical therapies with far too much authority. Convincing evidence exists that suggests the important role that psychotherapy plays in alleviating the symptoms of severe mental illness.

Overall, Jamison has produced an authoritative and passionate look at the importance of bringing suicide to the forefront of discussions about public health. She covers a difficult subject with compassionate insight and credible clinical research. Jamison is one of the bright lights of American psychology.