"It is argued that the other 10% also had mental illness but either the signs or the research were not strong enough to reveal the presence of a disorder." I think this is not a strong discussion because if the tests and research was not good enough for 10 percent then I can say maybe 90% is overdiagnosed as well. 

I seems important to me in suicide research is not only focusing on one area but having a multidimensional approach to prevent suicide. Because not each person who has mental ilness commit suicide. In suicide research, taking "risk factors" into account rather than already existed disease models, would be much promising to prevent suicide even before people diagnosed with mental ilnessess. One example to that could be "parental attachment". 

I hope I somehow contributed to your question. 

Tuba: Thank you for responding. My point is that the field's investment in the "mental illness model" is so strong and pervasive that accepting diagnoses on decedents based on the recollections of informants who have recently endured a traumatic loss is not only unquestioningly accepted but defended. That seems to suggest a paradigm.

Dear Tony Salvatore, I think "mental illness model" is a strong model for suicidality however there are cases in which one cannot decide whether the person who committed suicide was a victim of a mental illness or environmental risk factors, such as stress? I can give an example from Turkey that each year on June, "University Entrance Exam" was made and students were responsible of the all the lectures they learnt during their four year high school education. The university entrance exam was only lasting for 3 hours which created so much stress for the most of the Turkish students. According to statistics, people who ages 18-25, showed high suicide rate on the month of June of a year which correlates with the existence of the National exam. In that sense, I can say that environmental factors, culture, and so many other factors have to be taken into acount when we talk about suicide. 

Another point I can make is that diagnoses on decedents which based on the recollections of informants can be very deceptive. One reason I can give why these information can be deceptive is that suicide is a taboo in most of the societies and informants may not be objective to accept the occurence of a suicide from anything rather than a "mental illness". We know that suicide also in some cases is a political act. 

I like to enhance my way of thinking on suicide. I hope I do not sound hard when I talk. If I do, please mind it is because of my excitement about the topic.

Iya: Suicide is indeed "not always a representation of psychopathology." Except in the US where we give lip service to suicidal behavior as "complex" but always fall back on mental illness and mental health to explain it or prevent it.

Dear Tony

I agree with Iya and Tuba. The suicide is multidimensional problem with sociological, cultural and mental health factors. Its neccesary a multidimensional approach and not reduction to explain or prevent  it. 

What you are terming the 'mental illness model' is often referred to as the 'medical model'; that is, the medicalization of problems and presentations to services, and the tendency therefore within health and human services bureaucracies and hierarchies to give primacy to the medical voice and perspective.

Yes, in short, it would indeed appear that we have medicalized suicidality.

In all the ways you have described, community doctors and community services refer suicidal people to an acute medical setting. The acute medical setting refers to the appropriate medical specialty to address a problem of mood and the mind. People are thus medically cleared (or not) as safe to self and/or others by psychiatrists.

Psychiatrists are then charged with risk assessment, risk management and risk averse practices. This is actually a very ineffective way to manage suicide from the perspective of psychiatrists themselves, as well as from the perspective of the person and their family, and colleagues advancing psychosocial viewpoints and proposed interventions.

This makes it very hard to establish rapport, trust, a mutual understanding of the antecedents to the attempt, compassion, curiosity, a grasp of meaning, and a dialogue about options.

Just to be clear: I do not think that the singular focus, if not obsession, on mental illness in suicide research/prevention is at all positive. It skews attention form other factors and stigmatizes both those who are suicidal and those with mental illness. It may have produced calls for more mental heath services to prevent suicide but it does not seem to have produced more attention to suicide risk in mental health. 

Tuba's clear and relevant example of an incidence spike at exam times in young people under psychosocial stress is a wonderful example.

When I worked in suicide prevention telephone counselling for many years we would also witness a spike in numbers of calls and severity of mood in callers just after Christmas day; for some they were distressed at being alone, when perceiving others to be happier and to have people in their lives, and for others being with their family was a trigger for distress (old issues/wounds/regrets and expectations/animosities/misunderstandings...). Seemingly different reasons for suicidal thought, however there was a common theme evident that the holidays were prompting low mood, introspection and a subjective sense of missing out and having less worth in some people.

It would trivialise and reduce the rich humanity of these experiences to say only that the callers were experiencing a psychiatric crisis. It would also unnecessarily locate the pathology in the person, when they were clearly reacting to the time of year, social cues and expectations, behaviour in others, and in fact pro-social needs and desires to fit in, be happy, connect, etc.

Dear Tony

Thanks for bringing up this critical question and domain of discussion. While I believe this discussion has certainly been on the agenda for a long time, it's only now becoming more 'hot', and (at least in Australia), seeping into different government hands within the mental health folio's. There are two issues: What the emerging evidence is telling us - re mental illness being prevalent in fact, in less than (up to) 90% of suicide cases; and, whether such science actually gets translated into theoretically informed policy and/or practice efforts.

We recently did a study - below - entitled: Beyond psychopathology: Pathways to suicide in mentally well young adult males [as part of an Australian Research Council Discovery Project (2008-2011)].

The goal of this study was to investigate suicide risk factors among adult males in Australia (25-44 age) with no psychiatric diagnosis. The psychological autopsy (interviews with the next-of-kin of the suicide victims) was used together with analysis of coronial, police and medical files and compared with a control group of sudden death victims. The study investigated whether there are any differences in the contributing risk factors, their relative influences etc, in order to develop and implement targeted suicide prevention initiatives beyond those based on a medical/psychiatric treatment paradigm.

Articles are still being published I believe, but here is one below worth reading - which concludes by not only confirming the cultural differences in diagnosis and conceptualization of mental illness, but also the different employed methods for measurement of mental illness (which has a huge impact - especially since historically due to the predominant 'mental illness' model, we tend to 'search' for mental illness biased in the very questions we ask - rather than hearing the 'story' or experience of the individual). Plus, use of the psych autopsy method - based on interviewing of the NOK may is also known to be biased re this issue - simply due to the 'required need' to have an explanation attached to the suicide (not in all, but numerous cases). and several other issues.

... MILNER A, SVETICIC J, DE LEO D: Suicide in the absence of mental disorder? A review Psychological Autopsy studies across countries. International Journal of Social Psychiatry, 2012; ePub(ePub): ePub.

Another excellent recent article which may be of some use... especially for informing government policy and practice... and hopefully historical changes in our interpretations of this 'behaviour'.

Health and Psychosocial Service Use among Suicides without Psychiatric Illness

Yik Wa Law, Paul W. C. Wong and Paul S. F. Yip

With Joiner's and O'Connor's (welcomed) models however, must come useful and evidence based 'treatment' (also currently gaining momentum) which take a multifaceted approach to treatment - so that we not only 'interpret' the behavior as multifaceted, but such a model informs directly (and testable) treatment responses. I still think we need to direct much more NRG to this space (of investigation and response) since it is very slow to impact policy and societal deeply ingrained stigma. Japan is an excellent example of a suicide prevention action from a multifaceted perspective, with government mandated responses to SP from all sectors (health, mental health, transport, finance, drug and alcohol, workplace etc); and scientifically proven positive impacts.  Let us not forget that even if mental illness is a major factor in many cases, the issues experienced by the person as a result of the mental illness have been shown over and over again to be of high importance (e.g. discrimination re job opportunities; unemployment, stigma, isolation etc etc).

Yes Tony, I think we need a paradigm shift towards a more multifaceted understanding of suicide; which I believe is slowly coming; so that we target and impact 'all' those who are suicidal; with still due attention to those who's mental illness remains a major contributing factor.

WR

jacinta

The mental illness model assumes one size fits all...what may be considered mental illness in one culture, is not necessarily so in another...cultural analysis is paramount - therefore we need to rethink and shift the paradigm... One cannot discount sociocultural factors which impact upon suicidal behaviors.  

Interesting argument--raises key issue regarding the application of research to policy.

I very much appreciate all of the comments on my question. Attached is a very very very rough draft of a paper on the topic under discussion that I have been working on for some time. Disclosure: I do not feel that psychological autopsies are the greatest thing to have happened to suicide research or that their principal finding has done a great service to suicide prevention. 

The dogmatic universality of the "90% Law" just amazes me as much as I'm perplexed by the lack of any challenges (with few exceptions). It apparently applies to every age group, race, ethnicity, culture, religion, etc. Ran across this recently: "Ninety percent of young children who commit suicide have some kind of mental health disorder, usually major depression, Button said" (see link). Even the comparative handful of pre-adolescent suicide victims apparently manifest mental illness even though it is difficult to make a firm psychiatric diagnosis among those who don't take their lives.

http://www.apa.org/monitor/2010/10/suicide.aspx

In US suicide prevention it is almost anathema to separate suicide from mental illness or to not cast a psychiatric disorder in the starring role in any suicide. However, in Australia they have transcended our single-mindedness regarding the etiology of suicide and have a term for suicide absent any evidence of a DSM-V diagnosis: Predicament Suicide. This is defined as “…a suicide which occurs when the individual without mental disorder is in unacceptable circumstances from which they cannot find an acceptable alternative means of escape.” SeeArticle Predicament Suicide: Concept and Evidence