*57% Suicides Leave No Note

KISSIMMEE, Fl., 657 suicide death records reviewed 2003 to 2018, autopsied at the University of Iowa Hospital and Clinics in Iowa City.

Jane Persons, PhD, study reported, "57% left no communications of intent to commit suicide,"

281 left notes, 376 (57%) did not.
239 (36%) were under psychiatric care, got wrong help.

187 had a history of suicide attempts,

455 took place at home, 71 a vehicle, 60 on public property
509 men,146 women (gender was missing in two autopsy reports)

593 of the 657 were white
157 were married
men averaged age 43 and women averaged age 41

 

*Dr. Motto approach

Caring Letters Prevent Suicide

Proves those who received letters continued to have lower suicide rates even as the letters decreased in frequency and then stopped altogether.

Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services, 52(6), 828-833.

Problem

Suicide is a leading cause of death, and it is notoriously difficult to prevent.

Solution

Regularly receiving letters from a caring person helps people at risk for committing suicide feel connected.

The Details

Between 1969 and 1974, psychiatric hospitals in San Francisco admitted 3,005 people for depression or suicidal tendencies. Psychiatrist Jerome Motto and statistician Alan Bostrom randomly assigned some 843 of these patients to one of two groups after they were discharged from the hospital.

1. Contact group, patients received periodic 8 handwritten letters in the first year from a health care professional who had earlier interviewed them. The letters expressed concern, care, and a desire to stay in contact.. They then received 4 letters every year over the next four years, for a total of 24 letters over 5 years.

2. Control group, patients did not receive any letters from the hospital.

Two years after leaving the hospital (the span of time when at-risk patients are most likely to kill themselves) Only 1.peron in the contact group had committed suicide, compared to 3.52% of patients in the control group committed suicide. Even 13 years after hospital discharge, patients who had received letters from the hospital still had lower rates of suicide than those who had not.

Why This Works

Receiving regular letters that express care can help us feel connected to others. This feeling of connection is especially important during dark times. About 25% of patients in the contact group sent back grateful messages like:

"You will never know what your little notes mean to me. I always think someone cares about what happens to me, even if my family did kick me out," and

"It gives me great pleasure to know that someone is concerned."

When This Works Best

Many people at high risk for suicide refuse medical treatment, often because they don't want to be labeled as mentally ill. Communicating care and concern and creating a sense of social connection without demanding anything in return can help people survive the two-year period following a psychiatric crisis, when they are most likely to take their lives.

Kate Comtois, a renowned suicide researcher based in Seattle, funded by the Department of Defense, she and her team sent out text messages to hundreds of active duty Army soldiers and Marines. Each one got 11 Motto-style texts throughout the course of a year.

When the researchers focus-grouped the messages on active-duty service members, they were told that for this to work on Marines, texts should never imply weakness. "We were schooled," Comtois said. "They didn't want us to use the word 'need.'"

So she and her team kept the texts to the point: "hope life is treating you well" and "hope all's well and you're taking good care of yourself." The letters were texts, the researchers could reply to the soldiers with emoticons or whatever else felt natural. The study, showed recipients were less likely to have suicidal thoughts or make an attempt. Comtois was struck by how different the text interactions felt. "Most of the time we were reaching out to somebody who was happy to hear from us," she said. "That's just not how suicide care is."

Kate Comtois, said many therapists are untrained in how to treat attempt survivors, it may be difficult to handle a wave of patients if they seek help after receiving a caring letter or text.

And writing the letters can be tricky at scale. When the U.S. Department of Veterans Affairs first encouraged its facilities to send out cards to ailing vets, nobody imposed specific language, and many of the messages ended up straying from the therapeutic ideal. Some bugged patients about not answering the phone when a therapist called; others pestered them to eat better. They asked too much in return from the patients (breaking Motto's rule) and, just as bad, they expressed worry. Worry, sends the wrong message because it's "a statement that you don't really believe in them."

"Some therapists stand in the light and call out to the person in the darkness, 'Come out, there's light here, there's hope here.'" "But sometimes what the suicidal person needs is for the therapist to join them in the darkness and show them a way out."

Dr. Gregory Carter, who ran a psychiatry service in New South Wales , Australia , orchestrated a study in which Motto's words were typed onto a postcard. The notes were sent eight times over the course of 12 months to patients who were among the hardest to treat. The majority had histories of trauma, including rape and molestation. Some had made repeated suicide attempts. But Carter found there was a 50 percent reduction in attempts by those who received the postcards. When he checked in on the study's participants five years later, the letters' effects were still strong. The cost per patient was a little over $11.

Iraq Tehran, researchers ran a similar experiment, tweaked to fit the local culture. "In my mind, [the Motto text] was maybe boring for our patients," said Hossein Hassanian-Moghaddam, an associate professor at Shahid Beheshti University of Medical Sciences. "Maybe you think that it is somehow a robot that is sending you this kind of message." Instead, the Iranians wrote sentimental greeting cards packed with inspirational sayings or religious text. Some were inscribed with quotes from Albert Einstein. Others drew from Buddha or President John F. Kennedy. They also sent cards on the patients' birthdays (a favorite among the participants). The results were similarly positive.

Dr. Gysin-Maillart says, bring clarity to patients, the patient then receives Bern 's version of a Motto letter at regular intervals for two years. So far, the outcomes have been astounding: In 2016, the findings of a clinical trial were published, showing an 80 percent reduction in the risk of attempts which are fewer costly days in hospitals. 

No doctors prescribing medications. Instead, it was vigilant listening and letters, that solidified their sense of connection.

Anna a college student, replies to Gysin-Maillart, the letters ended up taking the form of long confessionals, giving details about her life that she hadn't shared with her therapist (whom she admired) or her mother (with whom she was on good terms). Anna came to see Gysin-Maillart as the keeper of all her secrets.

"I got your letter and almost didn't want to open it, because I wanted to preserve that feeling of joy a little while," Anna replied after Gysin-Maillart's first note. "Like when I don't open a present right away."

Three months after receiving her last letter from the clinic, Anna's insomnia was raging, she started thinking about suicide again. So she began writing an email to Gysin-Maillart. Just as she had in previous letters. But when she was done, she realized she didn't need to send it. Just writing, stopped her suicide behavioral.

Author information a 2-year study in Greece 42%,  left a note.

Psychiatric Hospital of Attica Dafni, 2nd Department of Psychiatry, Athens University Medical School , Athens , Greece . antparaschakis@yahoo.gr

Abstract

BACKGROUND:

Whether differences exist between those who do leave a suicide note and those who do not has not yet been comprehensively answered. Leaving a suicide note is not a random phenomenon: A minority, varying between 3-42%, of all suicide victims leave a note.

AIMS:

To compare the group of suicide victims who leave notes with the ones who do not, using data from the Athens Department of Forensic Medicine, the largest in Greece .

METHODS:

We examined existence of suicide notes. We completed psychological autopsy questionnaires after phone interviews with relatives of the suicide victims of a 2-year period (November 2007- thru October 2009).

RESULTS:

26.1% were Note writers, of our sample differed in the following: they died by hanging or shooting, had no history of psychiatric illness or recent (within 12 months of the suicide) psychiatric hospitalization.

 

Dr. Edwin Shneidman 15%  left a note. Searching records at the Los Angeles County Coroner's office, he discovered a stash of 721 suicide notes. Collected by the coroners between 1944 and 1953, but this meant that only about 15% of recognized suicidal decedents had left them.

One study cuts against these concerns. In 2004, researchers found that the more open therapists were to receiving calls from clients in between sessions, the fewer they ended up taking.

Dr. Bostwick explained in an interview. "That almost two-thirds end up at the medical coroner after a first attempt is astounding. We need to rethink how we look at the data and the phenomenon of suicide. We need to know more and do more for those who will complete suicide before they get to us for any kind of help."

Last Wills and Testaments in a large sample of suicide notes:
(implications for testamentary capacity).
Author information
Mark Sinyor, MSc, MD, FRCPC, Department of Psychiatry, Sunnybrook Health Sciences Centre and Department of Psychiatry, University of Toronto, Canada; Ayal Schaffer, MD, FRCPC, Mood and Anxiety Disorders Program, Department of Psychiatry, Sunnybrook Health Sciences Centre and Department of Psychiatry, University of Toronto, Canada; Ian Hull, BA(Hons), LLB, Partner, Hull & Hull LLP, Toronto, Canada; Carmelle Peisah, MBBS (Hons), MD, FRANZCP, School of Psychiatry, University of NSW and Discipline of Psychiatry, University of Sydney, Sydney, Australia; Kenneth Shulman, MD, FRCPC, Brain Sciences Program, Sunnybrook Health Sciences Centre and Department of Psychiatry, University of Toronto, Canada. Abstract.

BACKGROUND:
The leaving of a will prior to death by suicide is a relatively unexplored area.

AIMS:
To determine the frequency and details of will content in suicide notes.

METHOD:
Coroner records for 1565 deaths by suicide in Toronto (2003-2009) were reviewed for (a) will content and (b) the presence of depression, psychotic illness, dementia and intoxication prior to death.

RESULTS:
In total, 59 (20.7%) of 285 available suicide notes were found to have will content. Of those who left a will, 43 (72.9%) were reported to have a major mood or psychotic disorder, but none had dementia. Fifteen of 19 toxicology samples showed alcohol, sedative hypnotic/benzodiazepine, opioid and/or recreational drugs were present.

CONCLUSIONS:
A substantial minority of suicide notes may also include testamentary intent. The observed high rate of mental illness and substance use around the time of death has important clinical implications for understanding the mindset of people who die by suicide and hence also legal implications regarding testamentary capacity. Suicide notes that are particularly amenable to a systematic insight into the lexicogrammatical form of discourses of people in distress. Such insights, offer important clinical information that might underpin and enrich clinical/therapeutic action, as well as strategies of prevention. In other words, linguistically oriented discourse analysis can be a significant resource not for merely for research and distress, but also for clinical and preventive practice. Discourse analysis can be a powerful toolkit helping the practitioner (whether engaged in clinical action or suicide prevention) in unpacking the experiences of those who are at their most vulnerable. This unpicking, can lead to more nuance and hence better strategies to understand suicide.