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Article Excerpt
Suicide and suicide-related behavior (SRB) is a complex and multifaceted behavior. There are a range of behaviors and attitudes which fall under the banner of SRB, not all of which necessarily involve an immediate, explicit intent to kill oneself. Still many more can be seen to inhabit the grey areas between risky behavior and indifference. This article proposes that many studies of SRB fail to adequately describe the full extent and nature of the problem. This is particularly the case in problematic heroin users, many of whom regularly engage in behavior which can be interpreted as suicidal according to some definitions. The article employs qualitative data to provide concrete examples of some of the different types of SRB observed in a group of heroin users and argues for a stronger, more comprehensive nomenclature (a set of commonly understood, logically defined terms) of suicide.
Suicide-related behavior
Suicide is consistently reported to be one of the four major causes of death among heroin users, with heroin-related over-dose being the most common (Davoli et al., 1993). Death due to suicide among heroin users occurs at 14 times the rate of matched peers (Harris & Barraclough, 1997) and rates of suicide in injecting drug user (IDU) populations have been reported between 1% (Darke et al., 1996) and 49% (Neale, 2000). While there are most likely many reasons for different reported suicide rates, research methodology can play a substantial role (Heale et al., 2003) and qualitative investigations of the issue generally report higher rates than quantitative methods (see Neale, 2000). Differences in reported suicide rates between countries have not been systematically reported and meaningful comparisons remain difficult because of different study methodologies and samples, representing an issue which requires further investigation. However, there are other factors which influence SRB in heroin using populations. For instance, substantial gender differences have been observed in attempted and completed suicide, with females three times more likely to attempt suicide, and males three times more likely to complete (Darke et al., 2005). Previous research in Australia has also found that during 12 months of treatment there was no significant reduction in attempted suicide among males, but that females reported a significant decline in suicide attempts from 19.7 to 9.8% (Darke et al., 2005). The same study also reported major reductions in suicidal ideation and depressive symptoms due to treatment for both genders.
In the context of this article, it is important to begin with some definitions surrounding SRB which are drawn from O'Carroll et al. (1996):
Suicide
Death from injury, poisoning, or suffocation where there is evidence (either explicit or implicit) that the injury was selfinflicted and that the decedent intended to kill himself/herself (Operational Criteria for the Determination of Suicide (OCDS) definition).
Suicide attempt
A potentially self-injurious behavior with a nonfatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some (nonzero) level to kill himself/herself. A suicide attempt may or may not result in injuries.
Instrumental suicide-related behavior
Potentially self-injurious behavior for which there is evidence (either implicit or explicit) that (a) the person did not intend to kill himself/herself (i.e., had zero intent to die), and (b) the person wished to use the appearance of intending to kill himself/herself in order to attain some other end (e.g., to seek help, to punish others, to receive attention).
Suicide-related behavior
Potentially self injurious behavior for which there is explicit or implicit evidence either that (a) the person intended at some (nonzero) level to kill himself/herself or (b) the person wished to use the appearance of intending to kill himself/herself in order to attain some other end. Suicide-related behavior comprises suicidal acts and instrumental suicide-related behavior.
Suicidal ideation
Any self-reported thoughts of engaging in suicide-related behavior.
Figure 1 provides an example of O'Carroll et al.'s (1996) nomenclature. Key elements of this nomenclature are: The level of injuries sustained (no injury, nonfatal injury, or death which reflects lethality); intent to die from suicide; and instrumentality (whether or not the person wished to use the appearance of a suicidal act for some other end). Each operational category is defined by its own particular combination of the above three elements (Kidd, 2003; O'Carroll et al., 1996). This article focuses on the elements of these definitions which leave a wide margin for interpretation. Namely; that behavior is self-inflicted, that there is intent "at some level" and that evidence is either explicit or implicit. Clearly, interpretations such as "at some level" and "explicit or implicit" evidence require exploration and justification. For example, although long-term risky heroin use can be placed within the category of "Risk taking thoughts and behaviors" according to the definitions provided by O'Carroll et al., it remains to be seen whether it should inhabit a position along the continuum of SRB.
FIGURE 1 An outline indicating superset/subset relationships of the proposed nomenclature for suicide and self-injurious thoughts and behaviors 1) Risk-taking thoughts and behaviors A) With immediate risk (e.g., motocross, skydiving) B) With remote risk (e.g., smoking, sexual promiscuity) 2) Suicide-related thoughts and behaviors A) Suicidal ideation i) Casual ideation ii) Serious ideation (1) Persistent (2) Transient B) Suicide-related behaviors i) Instrumental suicide-related behaviors (ISRB) (1) Suicide threat (a) Passive (e.g., ledge sitting) (b) Active (e.g., verbal threat, note writing) (2) Other ISRB (3) Accidental death associated with ISRB ii) Suicidal acts (1) Suicide attempt (a) With no injuries (eg., gun fired, missed) (b) With injuries (2) Suicide (completed suicide) SOURCE: O'Carroll et al. (1996), p. 247
Differences in essential elements of the suicidal act, such as the level of intent and people's desired outcome, can result in very different perceptions and interpretations of suicide (Douglas, 1967). An important area where this occurs is intentional overdose in populations of IDUs and the level of ambiguity or indifference which they exhibit towards death (Heale et al., 2003).
Another confounding element is the complex problem of the validity of self-report. Respondents report some behaviors as being suicidal in nature, but when questioned, may answer in a negative fashion because they either do not fit within their perceived notions of suicide or they do not wish to be labelled according to the construct of "suicidal" (Kidd, 2003). This would be particularly problematic if they were only to be asked a single yes or no question (have you ever attempted to commit suicide?). Terms such as "intentional" and "deliberate" can be misinterpreted and it has been found that some people who deny "intending" to overdose were experiencing strong suicidal feelings at the time (Heale et al., 2003). Alternatively, participants may acknowledge the deliberateness of the event while having a relatively low intent to actually die (Heale et al., 2003). Certainly, in many cases, the person expresses ambiguity about his/her intent to die (Neale, 2000).
Indifference
Another complex phenomenon surrounding SRB in heroin users is the influence of indifference, or...
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