Suicide is not a medical diagnosis; it is a legal finding. The central features are that the death occurs as a result of actions taken by the deceased, and these actions were taken with the intention of causing death.
As mentioned, Esquirol (1
) was influential in the medicalisation of suicide in the early 19th century (18
); others describe this process commencing in the late 18th century. Our concern here, however, is with current practices.
Much Western academic writing has contributed to the medicalisation of suicide. For example, Moscicki (19
) states that “a psychiatric disorder is a necessary condition for suicide to occur”, and Jamison (20
) states that there is “unequivocal presence of severe psychopathology in those who die by their own hand”. Some authors state that a psychiatric disorder is present in 100% of cases of suicide (21
), and estimates of above 90% are widely reported (23
). These findings are based on psychological autopsies: evidence is gathered about the thinking and actions of the deceased, and conclusions are drawn as to whether or not a mental disorder was been present. These are retrospective studies, and there are serious reservations about their validity and reliability (25
) and the quality of the diagnostic instruments that are used (28
). Thus, the scientific quality of psychological autopsies is not proven.
Even if the methodological issues could be overcome with certainty, the possibility remains that distress may be medicalised and recorded as a mood disorder. It is reasonable to assume that all those who complete suicide are distressed, and therefore, psychological autopsy provides the opportunity for misclassification.
Recent Asian psychological autopsy studies have provided different results. An Indian study (29
) found mental disorder in less than 40% of decedents, and studies of young people in China (30
) have found an Axis I disorder in less than 50% of decedents. A report from Korea (32
) found that “the current suicide epidemic in Korea has social origins”. Given the potential for psychological autopsies to medicalise distress, findings that psychiatric disorder is present in less than 50% of the deceased suggests that medicalisation of suicide is much less common in Asia than in the West.
Another opinion, based not on psychological autopsies but on historical documents and qualitative material, acknowledges that suicide is more common among those with mental disorder, but holds that suicide can, and likely frequently does occur, in the absence of mental disorder (33
). It should be mentioned that Western sociological autopsies and reviews have provided support for social factors contributing to suicide (35
In addition to the psychological autopsy studies, a range of other actions encourage the medicalisation of suicide.
Officials (coroners, magistrates, et cetera, depending on local regulations) closely examine cases of suicide for evidence of health professional negligence or neglect, and frequently make negative findings (usually considered by the involved health professionals to be unjustified). By this process, officials reinforce the view that suicide is a psychiatric phenomenon and a matter of medical responsibility. Newspapers report these findings and supplement them with additional details. The police medicalise suicide by seeking to transfer everyone they apprehend who mentions suicide into the hospital system. They are motivated by the reasonable desire to avoid the hassles associated with a death in custody.
Suicidal thoughts (whether arising out of mental disorder or non-disorder distress) are terrifying to the individual and his/her associates, leading to a rush to a place of “safety” (the hospital). This is an understandable and often appropriate response in contemporary life, but can also be viewed in the context of medicalisation.
Self-help groups, some researchers and clinicians, and policy writers promote the notion that suicide is universally the result of mental disorder, because mental disorder is potentially treatable, and this notion allows the welcome belief that a path to suicide prevention is readily available.
When suicide has occurred, family members may prefer to believe and promote the explanation that the deceased must have suffered an unrecognised or untreated mental disorder, as a means of deflecting responsibility away from the deceased and survivors.
The great disadvantage of all-suicide-is-caused-by-mental-disorder thinking is that important social, cultural, economic, and political factors, about which much might be done, are neglected in favour of the medical solution. Relevantly, the medical solution has been the focus of national suicide prevention strategies around the world, but none of these have reduced national suicide rates (38
Another disadvantage of the medicalisation of suicide is that it leads to suicidal behaviour becoming a socially acceptable response to distress (certainly, this is the case among young people in the West). Thus, medicalisation of suicide makes suicidal responses more, rather than less, likely.
Those individuals who have a mental disorder and are at a risk of suicide should receive all possible help. At times of acute risk, they should be kept as safe as possible and the mental disorder treated. Special supervision and support may be necessary and involve admission (at times, involuntary) to the hospital. The individual who has lost all interest in food and fluid may need special treatment for malnutrition and dehydration, with a view to preserving life long enough for treatment to take effect, and emergency electroconvulsive therapy may be necessary. This is not medicalisation, but appropriate medical care.
Support can come from family, friends, clergy, teachers, and a range of people with experience of the world. However, the traditional extended family and religion currently provide less social support than formerly (certainly in the West), and scholars (39
) describe medicalisation as compensating for this social change.