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The relationship of suicide and mental disorder

The social control of psychiatric patients, both in hospital and community settings, is not limited to the question of violence to others. Mental health services are also concerned with reducing the incidence of self-harm and selfneglect. Rates of suicide among psychiatric patients are high for a number of reasons. Their labour market disadvantage places them in a demoralized and devalued position. Their primary disability may include profound feelings of anomie, aimlessness, worthlessness, low mood and low self-esteem, as well as angry feelings which can be trapped and turned inwards.

The secondary disability created by psychiatric treatment may be both demoralizing (when coping with drug side effects and stigma) and an opportunity to act suicidally (the option to self-poison with prescribed psychiatric drugs). The differential way in which psychiatric patients are treated when violent or potentially violent is also true of self-harm. In Britain suicide is not illegal. Despite this, suicidal patients, when identified, are treated in a peculiar way coercion is applied. The question of suicide in psychiatric populations is thus more contradictory in a legal sense than that of violence to others. The latter in any population, general or psychiatric, is judged to be both immoral and illegal.

By contrast, suicide is not illegal and its moral status is contested. Another example of the differential rule application to psychiatric patients in relation to suicide is more subtle and implicit. When psychiatric patients are suicidal, it is assumed that their intentions are governed singularly by their mental abnormality. However, suicides in nonpsychiatric populations are evaluated in a range of ways, which might include a notion of a temporary imbalance of mind, but other motives can be ascribed as well. These include a notion of rational intelligibility, when for various reasons, it is obvious why a person has little or nothing to live for (e.g. severe pain or physical disability or traumatic loss of significant others). Similarly, for reasons noted earlier, psychiatric patients might, for very good reasons, feel devalued and disabled.

And yet, suicidal intent or action on their part tend only to be interpreted as irrational. Thus, while the post hoc attribution of mental abnormality may be applied to any person committing suicide, there is a greater tendency for this to occur with people who are already psychiatric patients. Psychiatric diagnosis is a weak predictor of suicide. For example, those with a diagnosis of depression have a 15 per cent lifetime risk of suicide and for those with a diagnosis of schizophrenia it is 10 per cent (Morgan 1994). This means that the overwhelming majority of those with a psychiatric diagnosis do not commit suicide, although more do so than in the general population. When specific personal and social factors are taken into account, rather than diagnosis, then predictive validity increases. These factors include: drug and alcohol abuse; single or separated status; male gender; low social class; unemployment; poverty; previous parasuicide; age (variable according to diagnosis); and recent violence (received or given) (Platt 1984; Jenkins et al. 1994).

When suicide is reframed as a social, rather than individual, phenomenon then a range of public policy factors can be identified in relation to primary prevention. For example, in the US suicide rates are lower in States with tight gun control than those with lax control. An Australian study revealed that 85 per cent of gunshot deaths were linked to distress rather than criminal action (Dudley, Cantor and Demoore 1996). Suicide has increased with motor car use over the past 20 years (via carbon monoxide self-poisoning) but it decreased when North Sea (non-toxic) gas was introduced in Britain in the 1970s. Given that self-poisoning is a common means of suicide, then lax prescribing of psychiatric drugs by the medical profession increases suicide rates, as does the widespread availability of some over-the-counter drugs like paracetamol.

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