The interpersonal nature of suicide: a qualitative investigation of suicide notes

Their final words: An analysis of suicide notes from the United States

The present study sought to explore motivations (affective, relationships, life events, injury/medical diagnosis) in suicide notes (N = 49) from the U.S. Authors ranged in age from 18 to 74 years and were majority male (73.5%). Four raters analyzed the notes and, through a series of meetings, came to a consensus on the motives behind each note writers' suicide in terms of the broader motivational themes and the narrower second-level themes. All notes were primarily affectional in nature, with some gender and age differences. For example, suicide notes from males frequently refer to financial hardships whereas suicide notes from females were more focused on lowered self-worth and notes written by younger persons focused more on affect and relationships, while notes written by older adults focused on life events and marriage difficulties and separation. Findings illuminate the varied nature of suicide motivations but also highlight important patterns across groups.

Cognitive networks detect structural patterns and emotional complexity in suicide notes

Communicating one's mindset means transmitting complex relationships between concepts and emotions. Using network science and word co-occurrences, we reconstruct conceptual associations as communicated in 139 genuine suicide notes, i.e., notes left by individuals who took their lives. We find that, despite their negative context, suicide notes are surprisingly positively valenced. Through emotional profiling, their ending statements are found to be markedly more emotional than their main body: The ending sentences in suicide notes elicit deeper fear/sadness but also stronger joy/trust and anticipation than the main body. Furthermore, by using data from the Emotional Recall Task, we model emotional transitions within these notes as co-occurrence networks and compare their structure against emotional recalls from mentally healthy individuals. Supported by psychological literature, we introduce emotional complexity as an affective analog of structural balance theory, measuring how elementary cycles (closed triads) of emotion co-occurrences mix positive, negative and neutral states in narratives and recollections. At the group level, authors of suicide narratives display a higher complexity than healthy individuals, i.e., lower levels of coherently valenced emotional states in triads. An entropy measure identified a similar tendency for suicide notes to shift more frequently between contrasting emotional states. Both the groups of authors of suicide notes and healthy individuals exhibit less complexity than random expectation. Our results demonstrate that suicide notes possess highly structured and contrastive narratives of emotions, more complex than expected by null models and healthy populations.

Fight or flight? Exploring suicide thoughts, experiences, and behaviours among correctional workers and their interventions of agency

Research indicates that, relative to the general public and most other types of public safety personnel, correctional workers are more likely to engage in suicide ideation, planning, and attempts. Yet, less is known about lived experiences towards, of, and beyond suicidality among correctional staff. To contribute to this gap in knowledge, the current study draws on qualitative, open-ended survey response data (n = 94) to explore how Canadian provincial correctional workers navigate experiences of suicide, with a focus on the individual, personal, and social factors tied to experiences towards and of suicide thoughts and behaviours. By engaging the seminal works of Foucault, Žižek, and Deleuze and Guattari, we explore respondents' distinct forms of agency when grappling with, challenging, and transcending thoughts around suicide. We then discuss the research implications, with an emphasis on providing correctional workers with confidential, non-stigmatised well-being and treatment-seeking resources and processes, and more health care funding to fully cover timely and sufficient mental health treatment, prevention, and intervention.

Funeral arrangements requested by suicide decedents in Shanghai and Wuhan, China

This qualitative study analyzed suicide notes left by 591 decedents in Shanghai and Wuhan, in China. General guidelines and detailed requests with regard to funeral service were coded. In general, suicide decedents preferred untraditional funerals, which were simple and speedy rather than grand and costly funeral arrangements. These choices suggested that suicide decedents could fear stigmatization and discrimination. Some suicide decedents regarded suicides as vicious deaths, and thus wished their families to dispose of the cursed bodily remains and tombs as swiftly as possible.

Using suicide notes to understand suicide among cancer patients: A mixed-method study

BACKGROUND

Cancer patients are at risk of suicide. However, no studies have used suicide notes to investigate their expressed reasons for suicide. The objectives of this study were to compare the characteristics between note leavers and non-leavers among cancer suicide cases and to understand the patterns in expressed reasons for suicide using suicide notes.

METHOD

Suicide cases (2012-2017) were identified from the Hong Kong Coroner's Court reports, which provide detailed information as well as the content of suicide notes. Bivariate tests and multiple logistic regression were performed to compare the characteristics of note leavers and non-leavers among suicide cases with cancer. Thematic analysis was performed on suicide notes to extract themes of expressed reasons for suicides by cancer status and age group.

RESULTS

Among cancer suicide cases and compared to non-leavers, note leavers were younger, more likely to be male, use non-violent suicide methods, have better housing conditions, and live alone. Suffering from physical disease was a major theme identified among cancer note leavers across all age groups. Young and middle-aged non-cancer note leavers had various themes identified. Physical illness was the major theme for elderly non-cancer note leavers.

CONCLUSIONS

Cancer note leavers had unique characteristics and suffering from physical illness was the major expressed reason identified in the suicide notes. Healthcare professionals should pay attention to the mental as well as the physical needs of patients. Improving quality of life and regaining control of life are vital for suicide prevention among cancer patients.

Differences between suicide note leavers and other suicides: A German psychological autopsy study

INTRODUCTION

Suicide notes are not only the last personal message from the suicide victim to the bereaved, but are also a valuable source for research in preventing suicides. However, not all suicide victims leave a suicide note and it is unclear whether note leavers are representative of the general population of suicide victims.

METHODS

The aim of our study was to compare suicide victims who leave a suicide note compared to those who do not. Therefore, data from the Allgäu Suicide Study, which comprised detailed information on N = 626 suicides, were analysed using multiple regression analyses.

RESULTS

Of N = 612 cases with complete data, n = 255(42%) left a suicide note and n = 357 (58%) did not. Persons who wrote suicide notes before they killed themselves were more often female, less often married, found themselves more often in a financial or partnership crisis, and were more likely to suffer from a medical illness. They tended to poison themselves more often and were less likely to have a history of alcohol abuse disorder.

CONCLUSION

Suicide notes are one source to better understand the motives, which lie behind suicides and therefore may help to further develop and improve suicide prevention programs. Keeping in mind that suicide has heterogeneous reasons, the group of "note writers" might be one, which might especially have benefitted from psychosocial and psychotherapeutic interventions, as interpersonal relationships obviously played an important role even shortly before suicide.

Putting the Blame on Others in Suicide Notes From Shanghai and Wuhan, China

Abstract. Background: Suicide note leavers sometimes blame others for their death. The blame could reveal extrinsic suicide risk factors and thus countermeasures may be ascertained. Aims: This study included suicide note leavers in Shanghai and Wuhan ( n = 555) to examine (a) who was inclined to put the blame (b) on whom and (c) for what reason(s). Method: Logistic regressions were used to compare the note leavers who blamed others with those who did not. Cramer's V tests were used to examine the correlations between the note leavers' demographics and the targets of the blame. Results: Note leavers who used poisoning and cutting were more likely to blame others compared with those who used jumping, drowning, and hanging. Non-native note leavers tended to more frequently blame social problems and their workplaces compared with the natives. The common reasons for the blame on nonfamily members, children, and lovers/spouses were being mistakenly blamed for something, being disobedient, and having conflicts/hatred, respectively. Limitations: Some blame could have been made under the influence of psychiatric disorder/substances, and thus potentially deviated from the facts. Conclusion: Emotional/marriage consultations and family-therapy services should be made available to females experiencing love/family crises. Mental health services in the workplace could help reduce suicide risks.

A Quantitative and Qualitative Study of Notes Left by Youth Who Died by Suicide in Quebec from 1895 to 1985

The study of suicide notes and the evolution of their content could contribute to a better understanding of reasons conducive to suicide mortality and offer further prevention strategies. From 1895 to 1985, 706 coroner's inquests of individuals who died by suicide and were 20 years old or younger were found in the province of Quebec. Quantitative analysis compared those who left notes (n = 47) to those who did not leave notes (n = 659). Furthermore, notes were subjected to inductive thematic analysis. Sociodemographic characteristics of the deceased individuals did not change over time. Qualitative analysis revealed four superordinate themes: (1) last wishes, (2) to those I leave behind, (3) about me and how and why I did it, and (4) self-positioning in the world. Only the last theme evolved over the time period considered. Suicide notes shed light on the psychological state of the majority of young note leavers and suggest the persistent feelings of distress and entrapment before the suicide, which may be important factors for caregivers and family members to monitor.

Family, Health, and Poverty Factors Impacting Suicide Attempts in Cambodian Women

Abstract. Background: Our recent report demonstrates that 5.5% of Cambodian women have previously attempted suicide. Despite these high rates and critical need for intervention, research on suicide attempts in Cambodia is lacking, and life-saving information on suicide prevention is therefore unknown. Aims: This study explores factors impacting Cambodian women suicide attempts. Method: A total of 1,801 women participated in the large national survey during which 100 of these women (5.5%) reported at least one suicide attempt. Of the 100 participants 76 provided qualitative reasons for the suicide attempts. Only the 76 who provided the reasons for suicide attempt were included for analysis in this study. Results: Four major themes emerged: (1) family conflict, (2) emotional distress, (3) poverty, and (4) illness. Family conflict, emotional distress, poverty, and illness were all interrelated with each other; for example, women without money were unable to pay for treatment of otherwise treatable illnesses. Limitations: Owing to the nature of the data collection, member checking could not be conducted. Conclusion: Cumulative and intertwined personal, interpersonal, and contextual-level factors impacting suicide attempts included emotional distress, illness, family conflict, and poverty. Findings highlight points of intervention at individual, familial, and contextual levels to prevent suicide.

"I Can't Crack the Code": What Suicide Notes Teach Us about Experiences with Mental Illness and Mental Health Care

OBJECTIVE

While mental illness is a risk factor for suicidal behaviour and many suicide decedents receive mental health care prior to death, there is a comparative lack of research that explores their experiences of mental illness and care. Suicide notes offer unique insight into these subjective experiences. Our study explores the following questions: "How are mental illness and mental health care experienced by suicide decedents who leave suicide notes?" and "What role do these experiences play in their paths to suicide?"

METHOD

We used a constructivist grounded theory framework to select a focus of qualitative analysis and engage in line-by-line open coding, axial coding, and theorizing of the data. Our sample is a set of 36 suicide notes that explicitly make mention of mental illness and/or mental health care, purposefully selected from a larger sample of 252 notes.

RESULTS

The primary themes from our sample were 1) negotiating personal agency in the context of mental illness, 2) conflict between self and illness, and 3) experiences of mental health treatment leading to hopelessness and self-blame. These experiences with mental illness and mental health care can give rise to exhaustion and a desire to exercise personal agency, contributing to suicidal behaviour.

CONCLUSIONS AND RELEVANCE

This study highlights unique perspectives by suicide decedents, whose voices and experiences may not have been heard otherwise, addressing a critical deficit in existing literature. These insights can potentially enrich clinical care or strengthen existing suicide prevention programs.

Family, Health, and Poverty Factors Impacting Suicide Attempts in Cambodian Women

BACKGROUND

Our recent report demonstrates that 5.5% of Cambodian women have previously attempted suicide. Despite these high rates and critical need for intervention, research on suicide attempts in Cambodia is lacking, and life-saving information on suicide prevention is therefore unknown.

AIMS

This study explores factors impacting Cambodian women suicide attempts.

METHOD

A total of 1,801 women participated in the large national survey during which 100 of these women (5.5%) reported at least one suicide attempt. Of the 100 participants 76 provided qualitative reasons for the suicide attempts. Only the 76 who provided the reasons for suicide attempt were included for analysis in this study.

RESULTS

Four major themes emerged: (1) family conflict, (2) emotional distress, (3) poverty, and (4) illness. Family conflict, emotional distress, poverty, and illness were all interrelated with each other; for example, women without money were unable to pay for treatment of otherwise treatable illnesses.

LIMITATIONS

Owing to the nature of the data collection, member checking could not be conducted.

CONCLUSION

Cumulative and intertwined personal, interpersonal, and contextual-level factors impacting suicide attempts included emotional distress, illness, family conflict, and poverty. Findings highlight points of intervention at individual, familial, and contextual levels to prevent suicide.

"We Went Out to Explore, But Gained Nothing But Illness": Immigration Expectations, Reality, Risk and Resilience in Chinese-Canadian Women with a History of Suicide-Related Behaviour

Suicide is a complex and tragic outcome driven by biological, psychological, social and cultural factors. Women of Chinese descent and women who have immigrated to other countries have higher rates of suicidal ideation and behaviour, and immigration-related stress may contribute. To understand the experiences of immigration and their relationship with distress and suicide-related behaviour in Chinese women who have immigrated to Canada. 10 semi-structured qualitative interviews with Chinese women who have immigrated to Toronto, Canada and have a history of suicide-related behaviour were completed and analyzed using a constructivist grounded theory methodology. Immigration-related and acculturation stress stemmed from unmet expectations and harsh realities. These repeated experiences resulted in hopelessness, helplessness, and alienation, which are risk factors for suicide and suicide-related behaviour. However, immigration-related support can also increase hope, self-efficacy and connectedness to foster recovery and resilience. This is the first qualitative study focusing on immigration experiences and its relationship to suicide-related behaviour in Chinese immigrant women. Knowledge of immigration and acculturation stressors can a) help identify and support women at risk for suicide and b) form a target for social intervention for all immigrant women, regardless of suicide risk.

Male suicide among construction workers in Australia: a qualitative analysis of the major stressors precipitating death

Background

Suicide rates among those employed in male-dominated professions such as construction are elevated compared to other occupational groups. Thus far, past research has been mainly quantitative and has been unable to identify the complex range of risk and protective factors that surround these suicides.

Methods

We used a national coronial database to qualitatively study work and non-work related influences on male suicide occurring in construction workers in Australia. We randomly selected 34 cases according to specific sampling framework. Thematic analysis was used to develop a coding structure on the basis of pre-existing theories in job stress research.

Results

The following themes were established on the basis of mutual consensus: mental health issues prior to death, transient working experiences (i.e., the inability to obtain steady employment), workplace injury and chronic illness, work colleagues as a source of social support, financial and legal problems, relationship breakdown and child custody issues, and substance abuse.

Conclusion

Work and non-work factors were often interrelated pressures prior to death. Suicide prevention for construction workers needs to take a systematic approach, addressing work-level factors as well as helping those at-risk of suicide

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4500-8) contains supplementary material, which is available to authorized users.

A Mixed Methods Approach to Identify Cognitive Warning Signs for Suicide Attempts

This study used a mixed methods approach to examine pathways to suicidal behavior by identifying cognitive warning signs that occurred within 1 day of a suicide attempt. Transcripts of cognitive therapy sessions from 35 patients who attempted suicide were analyzed using a modified grounded theory approach. Cognitive themes emerging from these transcripts included: state hopelessness, focus on escape, suicide as a solution, fixation on suicide, and aloneness. Differences in demographic and baseline diagnostic and symptom data were explored in relation to each cognitive theme. We propose a potential conceptual model of cognitive warning signs for suicide attempts that requires further testing.

Who leaves suicide notes? A six-year population-based study

Popular culture insists on the significance of suicide notes, but research has yielded conflicting results about who leaves notes. Utilizing 6 years of suicides from a comprehensive statewide data surveillance system, differences were examined between cases with suicide notes and those without in terms of demographics, circumstances of the suicide, and precipitating circumstances. Of the 2,936 suicides, 18.25% included a note. Demographics and circumstances did not differ for cases with a note compared to cases with no note. Results have implications for working with people bereaved by suicide in helping understand that the notes are uncommon and not systematic. However, it is also possible that for some individuals, the content of a note is meaningful and can help or hinder their course of bereavement.

Characteristics of suicide notes of children and young adolescents: an examination of the notes from suicide victims 15 years and younger

OBJECTIVE

By analysing the suicide notes from suicide victims 15 years and younger, we attempt to gain insight into the process leading to youth suicide and explore the characteristics of the note writers.

METHOD

During a psychological autopsy on 42 youths, we were entrusted with 23 suicide notes in which we explored the themes and compared the note writers to the non-note writers.

RESULTS

The key messages were as follows: explain the reason for suicide, declare love and give instructions. The note writers had showed suicidal behaviour more frequently than non-note writers.

CONCLUSION

In the notes from youth suicide victims they present themselves as fully responsible and without confusion or overwhelming despair. The notes are likely equally informative as the notes of older victims.

Risk pathways for suicide among Native American adolescents

Native American (Native) adolescents have the highest suicide rates in the United States, yet no conceptual models describing risk factors specific to this population exist. We sought to further hone a Native-specific conceptual model developed from quantitative data with qualitative data collected from a longitudinal series of interviews with (N = 22) Native adolescents who had attempted suicide. Four levels of suicide risk emerged, detailing individual, family, community, and societal factors that affect youths' pathways to suicide, along with a variety of subthemes and constructs. Some themes parallel established models of suicide risk; however, others are unique to the experience of this sample, including the impact of overtaxed households and family composition, significant grief burden, contagion, and stigma surrounding treatment seeking. We suggest adaptations of existing themes and constructs in the model. We discuss practical implications for research and intervention development, along with strengths and limitations of the study.

Shame behind the masks: the parents' perspective on their sons' suicide

Suicides are more frequent among boys than girls. A tentative, conceptual model of processes behind suicide among boys and young men (aged 12-25), grounded in their parents' views, is presented. Extensive interviews with parents in 33 cases of suicide were analyzed using grounded-theory methodology. Family alliances, coalitions, and secrets interacted with the boy concealing problems and "hiding behind a mask," while the professionals did not understand the emergency. Four interwoven paths to suicide were found: the boy was hunted and haunted, addicted, depressed, or psychotic. Different forms of shame were hidden behind the masks of "the clown," "the warrior," and "the prince." Future preventive programs need to address barriers to communication among all parties involved.

Love and suicide: the structure of the Affective Intensity Rating Scale (AIRS) and its relation to suicidal behavior

BACKGROUND

Suicide has been linked to intense negative affect. However, little is known about the range of affects experienced by suicidal persons, or the separate effects of affect valence and intensity. We examine a novel self-report scale, the 17-item Affective Intensity Rating Scale (AIRS), and its relation to suicidality in a high-risk sample.

METHODOLOGY/PRINCIPAL FINDINGS

Patients presenting with suicidality were recruited from the Emergency Department in a large urban hospital, and completed a battery of assessments there. Structure of the AIRS was assessed using Maximum Likelihood Factor Analysis with Oblimin rotation. Convergent and divergent validity were assessed by regressing AIRS subscales against Brief Symptom Inventory subscales. Relation to suicidality was assessed by regression of suicide attempt status against scale and subscale scores, and individual items and two-way item interactions, along with significant clinical and demographic factors. 176 subjects were included in analyses. Three reliable subscales were identified within the AIRS measure: positive feelings towards self, negative feelings towards self, and negative feelings towards other. Only individual AIRS items associated significantly with suicide attempt status; strong 'feelings of love' associated positively with actual suicide attempt, while 'feelings of calm' and 'positive feelings towards self' associated negatively. Interaction analyses suggest 'calm' moderates the association of 'love' with suicide attempt.

CONCLUSIONS/SIGNIFICANCE

Factor analysis of the AIRS is consistent with a circumplex model of affect. Affective dimensions did not predict suicidal behavior, but intense feelings of love, particularly in the absence of protective feelings of calm or positive self-view associated with current attempt.

Suicide notes among Native Americans, Hispanics, and Anglos

Suicide is a significant health problem, yet many questions regarding suicide remain unanswered. One of the most frequently asked questions is related to motive: "Why did that person complete suicide?" We explored motivations for completing suicide, especially with regard to cultural differences, by analyzing suicide notes written by Native Americans, Hispanics, and Anglos in New Mexico. Five categories emerged describing motivation: feelings of (a) alienation, (b) failure or inadequacy, (c) being psychologically overwhelmed; (d) the desire to leave problems behind, and (e) reunification in an afterlife. The largest difference to emerge between ethnic groups was in the alienation category, which included more Hispanics and Native Americans than Anglos. The overall lack of differences in motivation among the ethnic groups suggests that commonalities in suicidal behavior outweigh the differences. Practical implications for research and practice are discussed, along with strengths and limitations of the study.