Serotonin Reuptake Inhibitors, Suicidality in Children and Adolescents.

There has been a major controversy in the media because of the relationship between suicidality in children and adolescents and SSRI antidepressants.  The FDA (Food and Drug Administration) in America state that antidepressants increase the risk of suicidal thinking and behaviour (suicidality) in children and adolescents with major depressive disorder and other psychiatric disorders.  Anyone considering the use of an SSRI or any other antidepressant in a child or adolescent must balance this risk with the clinical need.  Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behaviour.  Families and care givers should be advised of the need for close observation and communication with the prescriber.  Pooled analyses of short term placebo / controlled trials of nine antidepressants (SSRIs and others) in children and adolescents with major depressive disorder, Obsessive Compulsive Disorder, or other psychiatric disorders have revealed a greater risk of adverse events representing suicidal thinking or behaviour (suicidality) during the first few months of treatment in those receiving antidepressants.  The average risk of such events on drugs was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. This is a good and reasonable summary of the current situation.  It emphasises close monitoring in the early weeks and suggests close attention to risks / benefit of the medication.  Clearly the benefits will outweigh the risks in those with more severe depressive states.


It is interesting that efficacy could not be established for the SSRIs except for Fluoxetine in paediatric usage.  It is important as well to note that major depression increases the risk of childhood suicide about 12 fold.  More than half of the kids with this disease try to kill themselves, and about 7% do complete suicide according to USA Today 2004. One has to measure this against the fact that 2 in 100 children on antidepressants become more suicidal because of the pills and there were no reported suicides again according to USA Today 2004. The reasons for the increased suicidality might be due to the fact that the medications can increase impulsiveness and that as the children who have been depressed become more energetic this increases the likelihood of suicidality.  It is interesting that there isn’t evidence for the tricyclic antidepressants in children but the current controversy might drive clinicians because of the concerns about the SSRIs to go back to prescribing the tricyclic antidepressants which are generally regarded to have higher side effect rates. This would be a retrograde step.  The worry is now is that some severely depressed children wont get the antidepressant treatment they require because of the current controversy.  Indeed a report in USA Today states that some doctors ‘fear kids could be denied needed care’.  This is where the good clinician comes in who is able to weigh up the risks and the benefits, who is able to identify a depression as being severe and in need of antidepressant treatment.  Clearly mild depressions should be treated with psychotherapy.  The British Medical Journal 2004 came to a reasonable conclusion that doctors should not hesitate to use antidepressants for clearly defined depressive disorders but they should carefully monitor patients in the first weeks of treatment.  There is a signal for suicidality when you look at studies of antidepressants that is the SSRIs nevertheless a report in the Journal of the American Academy of Child and Adolescent Psychiatry 2004 stated that ‘none of the reported differences with regard to suicidality between any of the drugs and placebo are statistically significant’.  This report claims that there has been an underestimation of the reduction of suicidality in patients treated with antidepressants.  My own personal conclusion is that there is a signal for suicidality but this can be managed within the context of the doctor patient relationship and careful monitoring in the early weeks after prescription. It is difficult to communicate this common sense approach in the context of media controversy.



Suicidal Behaviour and The Male Brain

About 80% of all suicides are male.  Alcohol and substance misuse is commoner in males and unemployment may be a more significant risk factor in males who complete suicide. It appears that it may be harder for males to find their role and identity in our society where ‘a credit card is all you need’.


It is hardly surprising then that the unemployed male who may see themselves at the bottom of the male hierarchy is more likely to suicide.


Unemployed males would appear to suffer significant identity diffusion, be on a different track to other males, employed and driving their BMWs.


Indeed the difficulties with the male finding a role and being lost are particularly a feature of young male adulthood.  The Sunday Times in 2004 stated that ‘the sperm bank is the perfect father’ and had another statement as follows ‘women longing for a baby (but) decide to go it alone’.  The male has become more marginalized in our society in recent times. Females have entered the workplace in great numbers but still have retain their fundamental biological role that is in reproduction.


The male brain has strengths in mechanics, engineering, and mathematics.  These talents do not help in the mental processing of psychological distress. In addition males tend to be more aggressive, impulsive, and are therefore at increased risk of engaging in fatal suicidal behaviour. Simon Baron-Cohen points out that good systematisers are also skilled at understanding and exploiting natural systems.  The males are therefore good as hunters and trackers.  The male is good at mechanical systems and constructing tools.  The male is good at making weapons and fighting.  Good systematising helps the male to be good at working on the stock markets.  Males are particularly good at climbing hierarchical poles.  The combination of low empathising (male) and high systematising (male) means a rapid ascent to the top of the ‘social pile’.  Males are more single minded.  Nevertheless all these feature may make suicide more likely.


Males in severe psychological distress using the ‘stiff upper lip’ strategy are particularly at risk.  It is possible that some of them feel that being in distress is to be unmasculine is to be lacking machismo, which is experienced as intolerable, who then in this highly distressed state undertake suicide.  Males are better at map reading.  The male language is sometimes more egocentric.  Males are more aggressive and get involved in more crime and homicide.  Systematising is our most powerful way of understanding and predicting the law – governed inanimate universe.  Understanding the inanimate universe is not much good when a human being male is highly stressed and contemplating suicide.  A great deal of this material is also covered in my book Autism and Creativity: Is there a link between Autism in Men and Exceptional Ability?  Published by Brunner-Routledge, 2004.  The extreme male brain theory of autism is based on superior systematizing.


The female brain according to Simon Baron-Cohen is hard wired for empathy, and the male to understand and build systems.  In the long term it is likely that the human genome will pinpoint multiple genes of small effect that control empathising and systematising.  Females are better at sharing and turn taking, at responding empathically to distress of other people, are better at being sensitive to facial expressions, and value relationships more.


Empathising is the drive to identify another person’s emotions and thoughts, and to respond to these with appropriate emotion.  Females are high in empathising and low in systematising. Females are much better than males at reciprocal communication.  Females are also better at reading non-verbal behaviour. Females tend to be more compassionate and tolerant.  Females have superior capacity at communication and interpersonal relationships which may mean that they are less vulnerable to completing suicide.


The female has a more clearly defined role with reproduction and rearing children. Females are more developed human beings in terms of empathy and interpersonal skills.  They have better social skills.  They have better capacity to make social connections and are therefore less alienated and socially disconnected.  This may reduce their suicide risk.  (Prof. Fitzgerald is Chairman of the Irish Association of Suicidology)

Suicide In History.

John Donne ‘No man is an island, entire of itself … any man’s death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee’.


Suicidium is derived from the Latin words ‘sui’ self and ‘caedo’ to kill.  The Romans said ‘sibim mortm conscies consciscere’ in other words “procure his own death”.


Ancient authors against suicide include Pythagoras, Socrates, Plato, Aristotle, and Virgil.


Suicide in Ancient Greece:


During the Trojan War, Ajax, one of the Grecian heroes, slew himself, in a fit of passion, brought on by offended vanity. Lycurgus, the legislator of Sparta, was one who completed suicide.


Suicide in the Bible:


Judas Iscariot AD 33, Pontius Pilate AD 36, Zimri 929 BC King of Israel, Eleazar 164 BC, one of the Maccabees, Saul 1050 BC the first King of Israel, Samson 120 BC Judge of Israel.


Suicide in the 19th Century:


According to Westcott there were 24 suicides per million in Ireland in 1883.  This can be compared with 48 per million in Scotland in 1881 and 101 per million in Sweden in 1887. The rate in Switzerland in 1881 was 240 per million, in Denmark 265per million in 1878 and in Saxony 409 per million.  In the 19th century Briere de Boismont put the number one cause of suicide as mental illness but motive only counted for the most commonest assessment or lack of assessment of suicide.  The third cause of suicide was alcoholism.  Of the 600,782 cases observed by Falret the following proportions were calculated by him ‘caused by misery 1 in 7, loss of fortune 1 in 21, gambling 1 in 43, love affairs 1 in 19, domestic troubles 1 in 9, fanaticism 1 in 66, calumny, wounded self-love, and failed ambition 1 in 7, remorse 1 in 27’ For Lisle the first cause of suicide was mental illness, the second one was unknown, the third was to avoid pain, the fourth was domestic troubles, the fifth was debts, the sixth was misery, the seventh was habitual roguery. There were unusual causes including political excitement, religious fears, suicide after crime, rivalry in business, disgust of military life, disappointment in love, nostalgia.  Westcott in 1885 noted while crime was falling suicide was increasing and that while it awakens sympathy on behalf of the unhappy victims, we should stimulate our exertions towards promoting the diminution of this plague.


In the 1850s suicide was not more common in industrial areas than in rural areas.  At this time those at high risk for suicide were doctors, barristers, and butchers. At low risk were quarrymen, ministers, and fishermen.  It took a whole generation before people realised that railways could be used for suicide.  Morselli stated the prevalence of men over women was least in youth, greatest in adults, whilst it becomes small in old age.  Anderson points out that in the middle of the 19th century what was distinctive about suicide in the city was its exceptional frequency among young people, especially young men.  Indeed between 1861 – 1870 the suicide rate for young men and women aged between 15 and 24 years were respectively as much as 71 and 58% higher than those of the rest of the country.  Morselli warned women that taking part in politics would lead to ‘infallibly to higher suicide rates’.  Morselli believed that the emancipation of women would lead to higher suicide rates.  Durkheim (1897) comment was similar.  He said ‘women kills herself less . . because she does not participate in collective life in the same way’.  In the 19th century in married female suicide was often blamed on seduction according to Anderson.  Unfortunately at this period novelettes presented suicide as the appropriate response to a girl in difficulties.  Victorian domestic servants according to Anderson were believed to have high rates of suicide, as well as unwanted pregnancy, drunkenness and theft. Honeymoon suicides were also not uncommon.  The effects of masturbation were also a source of massive anxiety.  According to Anderson the chaplain’s office in Clerkenwell Prison was possibly the first suicide prevention agency and it focussed on churchmanship and social work.


In the 1870s emigration to Canada was offered to some who attempted suicide.  Alcohol was also a huge factor in 19th century Suicidology.  As Anderson points out there was a belief in the 19th century that suicide could be reduced if the press stopped reporting it ‘in detail’. This has echoes of today.

Suicide, Parasuicide, Suicidal Thoughts and Persons of Genius.

Dr. Arnold Ludwig studied the New York Times Book Review Biographies from 1960 to 1980 and found that 18% of the poets he studied had completed suicide.  According to Jamison Ludwig ‘compared individuals in the creative arts with those in other professions (such as businessmen, scientists, and public officials), he found that the artistic group showed two to three times the rate of suicide attempts’ (Jamison, 1993).


Jamison also points out that ‘biographical studies, as well as investigations conducted on living writers and artists, show a remarkable and consistent increase in rates of suicide’. She points out that ‘the artistic groups .. demonstrate up to 18 times the suicide rate’ compared to the expected rate in the general population.  This is higher than found in the Ludwig study.


Jamison points out (that the following artists completed suicide:  Heinrich von Kleist, Ann Sexton, George Trakl, Marina Tsvetayeva, Ernest Hemmingway, Malcolm Lowry, Virginia Wolff, Vincent von Gogh, Arshile Gorky, Mark Rothko, Nicolas de Stael, Thomas Lovell Beddoes, John Berryman, Thomas Chatterton.


Jamison also points out that the following made a ‘suicide attempt’: Charles Baudelaire, William Cowper, Edgar Alan Po, Percy Bysshe Shelley, Francis Thompson, Maxim Gorky, Hermann Hesse, Hector Berlioz, Eugene O’Neill, Mary Wollstonecraft, Robert Schumann, Dante Gabriel Rossetti.


Suicidal Thoughts:


A. Alvarez stated in his book The Savage God that ‘a suicidal depression is a kind of spiritual winter, frozen, sterile, unmoving.  The richer, softer, and more delectable nature becomes, the deeper that internal winter seems, and the wider and the more intolerable the abyss, which separates the inner world, from the outer.  Thus suicide becomes a natural reaction to an unnatural condition. Perhaps this is why, for the depressed, Christmas is so hard to bear.  In theory it is an oasis of warmth and light in an unforgiving season, like a lighted window in a storm.  For those who have to stay outside, it accentuates, like spring, the disjunction between public warmth and festivity, and cold, private despair’.  Lord Byron also suffered considerable suicidal thoughts. Percy Bysshe Shelley also experienced considerable suicidal thoughts.  Graham Green experienced suicidal thoughts.  William Styron in his book Darkness Visible wrote about his suicidal depression and stated ‘the pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come – not in a day, an hour, a month, or a minute.  If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul.  So the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying – or from discomfort to relative comfort, or from boredom to activity – but moving from pain to pain.  One does not abandon, even briefly, one’s bed of nails, but is attached to it wherever one goes’.  For Leo Tolstoy ‘the thought of suicide came to me as naturally then as the thought of improving life had come to me before’.


It would appear that the great artist experiences both tremendously deep and complex emotions.  They have access to emotional experiences and the extremes. The complexity of their emotional life is great.  All this is very helpful for their creativity but also makes them more likely for suicidal thoughts and suicidal behaviour.  They are less logical and rational then non-artistic people and are governed by the logic of emotions.  Of course the logic of emotions is very often not logical. This makes them more vulnerable to suicidal experiences.


K. Jamison in her book Night Falls Fast states that ‘I have a hard-earned respect for suicides ability to undermine, overwhelm, outwit, devastate, and destroy’.  Jamison is an Honorary Professor of English at the University of St. Andrews in Scotland has Bipolar disorder and has attempted suicide. This experience appears to be more common in persons with major artistic creativity than the general population.


Of course one has to be very careful with selected samples of geniuses with artistic ability.  They are no way representative of the total population of persons with artistic creativity.  Of course there is clear association between depression, suicide, and artistic creativity.  What the prevalence of these might be in the total population of artists in Ireland is unknown. We can’t generalise the total population.


It is interesting that both Ann Sexton and Abbie Hoffman received Manic Depressive Disorder diagnosis and were given lithium but stopped taking the lithium and completed suicide thereafter. It is possible to reduce the suicide rate in artistic people with proper treatment of their psychiatric problems. It is likely that the vast majority of artistic people who complete suicide have psychiatric problems. Clearly an additional factor is that abuse of alcohol and drugs is not uncommon in artistic people.  There is a myth that alcohol increases creativity. What alcohol does is to increase depressive feelings and not creativity.  Alcohol and drug abuse is clearly also associated with depression. Indeed it appears to me that being creative is what keeps people alive.  It would appear to me that suicide and depression are much more common where the artist experiences a creative block and that they are particularly vulnerable at that point.  The great philosopher Ludwig Wittgenstein as illustrated in the book Autism and Creativity was able to resist suicide by a continuing ability to be philosophically creative as a research philosopher.  Indeed it may be that a creative block leads to depression leads to alcohol abuse leads to suicidal behaviour.


In terms of social drinking this is an entirely different matter.  It is unlikely that ordinary social drinking will have a negative effect on creativity and indeed might have a positive effect.  Stephen Pritzer points out that ‘many writers recognise they could not write well while they were drinking.  F. Scott Fitzgerald and Ring Lardner said they went on the wagon when they worked’.  He also points out that ‘writers who used alcohol occasionally saw it as an aid in getting started or a stimulus when they were tired’.  This makes sense.  Clearly excessive drinking is damaging but smaller amounts might be positive for social functioning and indeed for physical health generally.  One must also remember that there is often a depressed period following a creative spurt.  This has to be managed by a creative writer.  Of course in addition the vast majority of artists are poorly paid and suffer a great deal of financial stress.  It is a very insecure profession.  It is hardly surprising therefore then that it is stressful and this stress makes people in this profession more vulnerable to anxiety and depression. Clearly there are genetic factors in relation to creativity, alcohol abuse and depression. The alcohol abuse only makes it much more likely that the artist will not be able to produce their potential. I don’t believe the story that Coldridge wrote Kublai Khan while on opium.  If it is true then he could only have been taking very minor amounts. It is interesting to compare this with great mathematicians, scientists, and inventors (Fitzgerald, 2004).  The stress in their life was generally much less than those with artistic creativity.  In addition great scientists, inventors, etc. often find very useful places for themselves in society either in the academic world or in the industrial world and therefore do not have insecure lives from a financial point of view.  They are also in general far better paid financially. Not every highly successful artist is capable as well of dealing with fame.  They may feel they have to continue to produce great work which they may no longer feel able to.  They may engage in self destructive paths of drinking and notoriety with suicide as an outcome. Being successful may set the bar too high for them and they may be unable to repeat it and therefore develop writers block followed by depression and alcohol abuse.




Ludwig A. M. (1992).  Creative Achievement and Psychopathology:  Comparison among Professions.  American Journal of Psychotherapy, 46, 330 – 356.


Jamison K. (1993).  Touched with fire.  Free Press: New York.


Jamison K. (2000). Night falls fast.  Picador.


Alvarez A. (1973).  The Savage God.  Random House: New York.



Styron W. (1990).  Darkness Visible.  Random House: New York.



Pritzer S. (1999).  Encyclopaedia of Creativity.  Academic Press:  San Diego. Edited by M. Runco and S. Pritzer.



Fitzgerald M.  (2004).  Autism and Creativity.  Brunner Rutledge Hove.



Suicidal Behaviour in Adolescents

Worldwide there is about one death every 40 seconds and about one million suicides per year.  Suicide is the leading cause of death worldwide, particularly in younger people.


According to Dr. John Connolly there has been a twelve-fold increase in suicide between 1960 and 2000 in 15 to 34 year olds. The Union of Students in Ireland has estimated that 25 persons per year between the ages of 20 and 24 complete suicide. In data collected during 2002 the National Suicide Foundation Registry found that there was increased Parasuicide by 5.7% in the Midland Health Board, 11.9% in the Mid Western Health Board, 8.5% in the South Eastern Health Board, and 12.7% in the Southern Health Board.  They also pointed out that Parasuicide was highest among young women aged 15 to 19 with 1 per 160 of the total population of 15 to 19 year olds being involved.  Parasuicide rates were higher in urban areas and varied between 63 per 100,000 in Leitrim and 429 per 100,000 in Limerick.  They found that alcohol was involved in 46% of male suicides and 38% of female suicides.  Parasuicide made up 1% of all casualty attendances.  The types of drugs used in overdose include (a) 40% minor tranquillisers, (b) 43% at least one analgesic drug (Paracetamol involved in 30% of drug overdoses), (c) 23% antidepressants (18% SSRI), (d) Paracetamol was involved in 33% of overdoses by women and 23% of overdoses by men.


It is clear that there are major associations between suicidal behaviour and alcohol or drug abuse.  There is a higher risk if there is an easily available method and higher risk in populations of persons who are depressed and persons with schizophrenia.  Hopelessness is closely associated with suicidal behaviour.  Other factors include narcissistic wounds to the personality i.e. shame or public humiliation.  Imitation plays a role for example after Marilyn Monroe’s death. Unemployment and genetic factors are also important.  The social contact factors include anomie, alienation, western industrialised societies, sense of meaningless in life, ‘worship of the Euro’, a history of sexual abuse, drop out from education, and bullying can also be factors.  Other factors include poor problem solving skills, relationship problems and loneliness, as well as having a history of impulsivity and Attention Deficit Hyperactivity Disorder.  Another condition sometimes involved is persons with Asperger’s syndrome, which is a social relationship disorder.  Personality features associated with suicide and behaviour include antisocial behaviour, emotional dysregulation, and depressive personality.


Males are at increased risk of suicide because it is harder for them to find an identity in our society and they often have a sense of being lost.  They have greater difficulties in expressing their feelings particularly emotional feelings and describing interpersonal difficulties.  The female has better verbal skills, better empathy, better interpersonal skills than the male and this is important in reducing completed suicide. The male mind is more of a mechanical mind which is less good at emotional processing.


Almost anything can be a warning sign of suicidal behaviour in adolescents but the following have been noted:  truancy, poor school performance, anxiety and depression, withdrawn behaviour, change in behaviour, sleep disturbance, impulsiveness, and low frustration tolerance.  Protective factors against suicidal behaviour include prior experience of self-mastery and success, good mental health, and healthy socialising and coping strategies, as well as success at school and work.


In assessing the adolescent with possible suicidal ideas or actual suicidal ideas it is important first to listen and then not to panic and to realise that purely legalistic thinking will interfere with one’s ability to listen to the patient.  It is important to ask relevant questions including thoughts and intensions about suicide, plans, wills, available methods, family history of suicide, imitation issues, depression, and hopelessness.  If a school teacher or anybody else becomes aware that an adolescent is suicidal it is important to remain in touch with them to give them a telephone number or mobile and to take action to bring the matter to the attention of their family.  It is one of the few areas were confidentiality to a friend does not apply. Keeping the friend alive is all that matters.  The adolescent will often need to get first in touch with their G.P. and then with a Psychiatrist or Psychotherapist / Counsellor to deal with the matters that are concerning them.  Sometimes these contacts need to be on a daily basis in the early stages of treatment.


In terms of postvention that is dealing with a family post suicide it is important to avoid fault finding or blame. Truthfulness is very important. The family need time to work through the feelings they have in relation to the suicide and this may reduce the likelihood of intergenerational effects later on.


In terms of suicide prevention in schools it is important that adolescents are helped to deal with stress and distress and learn life skills.  They have to be thought to manage stress, loss, how to manage upset of a break-up of a relationship, and academic problems.  Developing problem solving is critical.  Some isolated students also need very much to develop social skills and active programmes to prevent bullying in school are of critical importance.