The Question of Suicide

50 years of research on the mental health issue that was supposedly inscrutable



Washington University researchers invented what is now known as a "psychological autopsy."

Research has shown that most people who make suicide attempts don't really want to kill themselves. They're hoping to change their lives.

It's impossible to study suicide. That was the conventional wisdom in the 1950s, despite years of progress in psychiatric research and treatment. But two Washington University psychiatrists, Eli Robins and George E. Murphy — who launched the first systematic study of suicide 50 years ago — were convinced otherwise.

"Early in my career, I wouldn't have bet a nickel that we would ever see acceptance, because there was so much disparagement of these ideas," recalls Murphy, MD, emeritus professor of psychiatry. He and the late Robins, former head of the Department of Psychiatry, first presented their work in 1958 at a meeting of the American Public Health Association in St. Louis.

Two other "authoritative-sounding" speakers first presented pa-pers about suicide —each one asserting that it was "impossible to study because the people who did it were already dead," says Mur-phy, recalling the way Robins began his presentation that day. "Eli said: 'Well, we're just simple country folk, and we hadn't realized the impossibility of our task.'"

Seminal papers published by Murphy and Robins created a whole new area of psychiatric research. Their work has been cited nearly 800 times by scholars from more than 300 universities in 32 countries. Not bad for a subject that's impossible to study.

Robins and Murphy looked at 134 suicides in St. Louis City and County from May 1956 to May 1957. They used a systematic inter-view containing a few hundred questions to gather information from relatives, physicians, landladies, co-workers and anyone else they could find who had regular contact with the person who had com-mitted suicide.

Interviews often took more than two hours to complete. The re-searchers, who were given the names of the deceased by the coroner, always waited at least six weeks before contacting friends and family of suicide victims. Those interviews were uncomfortable for Murphy.

"I didn't like doing it," he says. "People got emotional, of course, about their loss. Some of them said they felt better after talk-ing with us, but a lot of them felt worse."

Robins and Murphy invented what is now known as a "psycho-logical autopsy," which uses post-suicide interviews to better deter-mine the cause of suicide. Since that first study, many additional studies have validated their findings.

After the interviews were completed, Robins and Murphy spent evenings together using a new system of diagnostic criteria — that later would become the basis for the American Psychiatric Associa-tion's Diagnostic and Statistical Manual — to "diagnose" the psy-chiatric health of the suicide victims. They found that at time of death, at least 90 percent had some form of psychiatric illness.

The most common diagnosis was depression, followed by alco-holism. And those remain the two most common psychiatric problems affecting people who take their own lives.

That early suicide research gave hope to those who wanted to intervene and prevent people from taking their own lives. Murphy and Robins found, somewhat surprisingly, that most people had vis-ited a physician within six weeks prior to their suicide. At least two-thirds had told someone they were thinking about ending their lives. Subsequent research determined that although most wouldn't volun-teer their suicidal intentions to a physician, they would talk about it if asked.

So the idea was hatched to give people considering suicide a special place to call, where they could speak with trained volunteers and be referred for professional mental help.

Noted St. Louis social worker Sydney Jacobs proposed the idea of a suicide hotline to then-coroner Richard Harris. Because Harris had an ongoing relationship with Murphy and Robins through their research, he proposed involving them in the project

The Suicide Prevention Hotline, now known as Life Crisis Services, opened in 1966. Since then, thousands of people have called.

"George and Eli repeatedly found that most people who make suicide attempts don't really want to kill themselves," says Richard D. Wetzel, PhD, professor of psychiatry, neurology and neurological surgery.

Failed attempts fall in one of three categories: those who were rescued or couldn't properly carry out their chosen method, those who didn't know or care what would happen as a result of their ac-tions, and those who made the attempt in an effort to change their lives.

Most "successful" suicides, on the other hand, involve people who can't see a way to improve their lives; they simply want to end them.

Wetzel was the hotline's director in its first year, and he worked with Murphy on a study of hotline callers designed to learn whether they tended to be more like the people who go through with suicide or more like those who threaten or attempt suicide in hopes of mak-ing life better.

"The probability that a caller was going to commit suicide was really quite low," Murphy says. "They were upset, no question about it, and yet their characteristics did not fit the typical suicide."

In fact, most of the phone calls that seemed connected to serious suicidal intentions involved third parties who called the hotline to re-port someone they suspected was suicidal.

Although psychiatrists have known about many suicide risk factors for decades, it's still true that people who could be helped fall through the cracks. That's a lingering frustration for Murphy.

"I think it's clear that many suicides have been prevented over the years," he says, "but the suicide rate hasn't really changed. To this day, suicidal persons who have seen a physician have been un-dertreated, if not untreated, for depression."

And while much has changed in the 40 years since the hotline opened, and in the 50 years since the research began, one thing hasn't changed: Suicide remains relatively rare, representing less than 2 percent of total deaths in the United States.

Still, Murphy feels more can be done. He firmly believes that suicide should be high on the list of routine doctor-patient discussions. The lingering problem of suicide, he says, is not so much the failure of psychiatric treatment as it is the failure to treat psychiatric illness.

Lifeline celebrates anniversary, honors founders

The St. Louis-based social service agency Provident recently held a special ceremony to mark the 40th anniversary of its Life Crisis Services (LCS) hotline. The event, held at The Ritz-Carlton in Clayton, honored those who have assisted LCS in its mission of helping individuals at risk of taking their own lives.

Founded in 1966, Life Crisis Services is one of the oldest such hotlines in the nation. Its trained volunteers, under the supervision of clinical staff, provide round-the-clock, telephone-based suicide prevention and crisis intervention services to more than 40,000 callers each year.

Hotline volunteers are trained to ask callers specific questions. For example, questions about sleep patterns or feelings of sadness can provide clues about whether the caller is depressed. Questions about drinking and drug use also provide important information. They'll even ask how old the caller is, knowing that impulsive teens are at particular risk, as are men who've recently retired.

Three Washington University School of Medicine faculty were honored at the event: George E. Murphy, MD, emeritus professor of psychiatry, the late Eli Robins, MD, former head of the Department of Psychiatry, and Richard D. Wetzel, PhD, professor of psychiatry, neurology and neurological surgery.

Murphy and Robins were recognized for their involvement in the creation of the hotline, while Wetzel was lauded for his early and continued support of the effort. Murphy and Wetzel remain members of Life Crisis Services' Founders' Committee.

"When you consider what is required to make this work your profession," says Kathleen Buescher, president and CEO of Provident, "it is extraordinary that so many people in our community find it in their hearts to become involved."