Keywords

Escape; pain; illness; depression; financial; legal

Escaping From Multiple Issues

When Jim was in high school he used to cut himself just to feel the pain. He said, “When you are first born and through childhood you are happy, you bounce back from so much mentally and physically, you have pure goodness. As you get older you start to realize that life is pain, and we are all wired for pain. You spend your time thinking of the future but when you get there all you think about is the past. NO ONE is ever truly happy at any time. Life is pain and anyone who says differently is trying to sell something.”

Eventually he began to burn himself as well. He wrote, “I have now heard the sound of my own flesh burning. When I put something red hot, and I do mean glowing red against my skin, it makes a crackling sound, like rice crispy’s. Yum. Only this makes me feel relaxed.” Jim was both obese and a heavy smoker. At 22 years old he had a massive heart attack which left him debilitated and depressed. He also had permanent heart damage, which made his dreams of being a firefighter impossible, so he decided to go back to school. At school, drinking replaced his self-mutilation as a way to alleviate some of his social anxiety. He stated, “Drinking is a temporary relief to my pain, so is cutting and burning (not to big on burning).” However, his drinking made it impossible for him to keep up with his classes, and he was placed on academic probation. Jim moved back in with his parents and began working at a local grocery.

Jim had always considered suicide. He wrote, “All my life I have thought about suicide. How I would do it, where I would do it, I always have thought about it but I have never planned it or even started to think or consider planning it. For the last month or two I have started planning it. This is a huge difference from before because I don’t just want to do it anymore, I am going to do it.” One afternoon Jim came home from work, went to his room, smoked some pot and perused some pornographic magazines. Then he pointed a handgun at his faulty heart and pulled the trigger. In his note Jim said, “2 rules to life. 1. There is always a victim. 2. Don’t be it. I am tired of being a victim.”

Ed was a contractor who lost his small business when the bottom dropped out of the economy. Although he applied for many jobs, he could not find employment. He suspected that because he was in his late fifties, no one wanted to hire him for a manual labor job. He was upset that he could not provide for his wife and four daughters and this eventually led to depression. He dealt with the depression by withdrawing to his bedroom where he would remain for long periods of time. He began having physical problems and was diagnosed with high blood pressure. Ed refused to take his medications and had a stroke. When he was discharged from the hospital, he began threatening suicide. On one occasion, he left the house with a gun which he placed under the seat of his car. Fearing for his safety, his wife called the police, and Ed was arrested for carrying a concealed weapon. A few weeks later his 14-year-old daughter came home from school and found him dead on the couch. He had taken an overdose of pain pills, then shot himself in the head. In his note he said, “Too this end, I give up this life. Despite everything I’ve done the best I could. I am just too tirid to keep on ‘keepin on.’ No I don’t feel sorry for myself. Its just a good day to die. What has taken me so long is to try doing it without leaving a mess for the girls to find. I love you.”

Jim and Ed represent the largest group within the escape category, those who had killed themselves to escape multiple problems (258 people). These individuals are similar to the other escape categories in that they are trying to end some pain or psychache, but unlike other escape categories, not one precipitant is identified. For example, in the physical escape category, the primary precipitant is pain related to some physical cause. Individuals in the escape multiple group were struggling with pain from numerous stressors including any combination of physical, psychological, financial, legal, or interpersonal problems. For Jim, these were lifelong stressors but for Ed, unemployment led to a downward spiral that resulted in a pain too great for him to handle. Sometimes the spiral takes years but other times, such as with legal involvement, it can take days.

Similar to our overall sample, and every subgroup, the victims were mostly Caucasian (94%) men (82%) who killed themselves at home (76%). The average age was 47 with a range of 11–89 years old. Although it may be hard to imagine how an 11-year-old could have a multitude of problems that caused unbearable pain, the confluence of circumstances, misery, an inability to envision an end to the pain, and a lack of appropriate and sufficient help can push even young people into suicide. Jordan, the youngest person in the sample, suffered from seizures, allergies, and asthma for most of his life. He recently had been expelled from school for behavioral problems and was referred to therapy for his depression. For years, Jordan had been saying that he wanted to die. Unfortunately Alice, his mother, was having difficulty finding a mental health provider that accepted her insurance. One day Alice went to the grocery and when she returned she found Jordan “sleeping” in his closet. She did not notice the tie wrapped around his neck. Later, when he did not come down for dinner, she realized something was wrong, but it was too late to revive him. Like Jordan, each of the very young children in our sample had a long history of multiple problems.

Some of Jordan’s problems were representative of the other individuals in this group. At least half had physical problems (50%) or substance abuse problems (50%), or both. Twelve percent spoke of their disabilities in their notes. In addition, approximately three-fourths (73%) had identified psychological problems such as depression (80%), bipolar disorder (5%), schizophrenia (1%), multiple diagnoses (8%), or miscellaneous other diagnoses (5%), such as anxiety. One-fourth had previously attempted suicide, 24% had made threats and 22% had suicidal ideation. When these victims wrote of their psychological pain, it sounded remarkably similar. Their feelings were expressed in the strongest terms.

Christy began abusing drugs in high school. At 42 years old she was in a near-fatal car accident that left her with facial distortions and a physical disability. Although she was able to break free of her addictions, she was severely depressed. In her note she said,

Paul and Suzanne had been high school sweethearts. When Suzanne was diagnosed with breast cancer, they vowed to fight it together. Unfortunately, she died just before her 50th birthday. In the 12 years after her death, Paul struggled with depression and attempted suicide several times. His depression was so severe that he was on disability. A few months before he committed suicide, Paul began a new relationship but they broke up because Paul could not move beyond his depression. He wrote, “I have begged God over and over for years to please take me home out of my mental anguish, and yet here I am. Why does God torture me? Why doesn’t he help me??”

Christy exemplifies the interpersonal problems that many individuals (47%) were dealing with in this group and 37% spoke about in their notes. Christy isolated herself but other people talked about lost or unrequited love in their notes. Although some of these endings were recent, many, like Paul, were still suffering years after the end of the relationship. One man described the loss saying,

Although there are many stories similar to this relating to the loss of a partner, rarely did interpersonal problems that involved domestic violence occur in this group (5%).

Other interpersonal problems were not due to lost romantic relationships, but caused instead by strained interactions with family members. Lori was conflicted about whether to press charges against her daughter, who had stolen $1000.00 from her, thus causing a financial crisis. Lori struggled with mental and physical health issues as well, and while she was hospitalized for her depression, her daughter stole her credit card. The last straw was when Lori learned her insurance would not cover her hospital bill. She wrote,

Overall, financial (41%) and legal (35%) problems were almost as prevalent as interpersonal problems among those trying to escape multiple issues. In their notes, 24% talked about financial problems while 18% referred to their legal problems. Inadequate medical insurance was occasionally a complicating circumstance, as with Jordan and Lori. Oftentimes, as with Lori, the legal and financial issues were intertwined with interpersonal, physical, or mental health problems. Occasionally, other problems were mentioned in the notes such as employment (16%) or school (6%).

Fifty-one people in this group (20%) left notes and most of those (61%) left only one note. Most notes (63%) were addressed to a specific person and were signed (59%). Some evidence existed of tunnel vision or constricted thought processes (29%) and/or dichotomous thinking (14%) in the notes. For example, an elderly man with multiple health issues wrote this note to his wife of 50 years, “I did not want to do it this way, but all other alternatives scared me. I did not want to postpone it any longer on account of finances, and I was getting so bad. I could not even read anymore. It will take you awhile to adjust but it looks like you will have a good future. ‘Your Loving Husband.’”

Most people talked about their love for others (75%), mentioning their children (41%), partners (39%), parents (33%), siblings (16%) or other family (27%), and friends (22%) in their notes. Fourteen percent said they felt loved by others. It is not surprising then that many (63%) felt a need to provide some justification for their actions, sometimes identifying a precipitant (20%). Some directed apologies to specific individuals (47%) while others offered general apologies (33%) or asked for forgiveness (37%). They absolved others from blame (24%) but sometimes blamed others (18%).

Some note writers specifically said life was not worth living (25%) or they needed to escape (35%). Paul, in his early sixties, said, “I just couldn’t take any more of my nothingness life. It was beyond horrible.” Adam had struggled with substance abuse and physical illness since he was an adolescent. In his second year of college he was expelled when he assaulted his roommate during a night of heavy drinking. He said,

However, even if the note writer did not explicitly discuss the need to escape, or say that life was not worth living, the overall tone of all the notes reflects these sentiments. Some instead referred to their physical (27%) or psychological pain (31%) or just talked about unspecified pain (12%). Still, never was just one source of pain cited, but many, often of interrelated origins.

When note writers did refer to the afterlife (31%) it was often in relation to their present circumstances. One man in his midforties said, “To my family, I am very sorry, I know you have been through enough. Life is not worth it. I will take my chances on the other side!! I love you all. ME. I just wanted help, It is overwhelming (LIFE) I’m sorry.” Some talked about God (26%): “May God have mercy on my soul. I have not been the best. I am so lost. I am so weak...And to all don’t grieve, my Father has prepared many rooms for me.” A small number envisioned God watching over loved ones (13%). Some despaired that there was no God. “I just wished there was a God to help me in these final moments of loneliness,” one man lamented in his note. He then shot himself in his vehicle in the parking lot of his sister’s apartment building.

Others spoke of reuniting with loved ones who were already deceased (8%) or after those who are alive have died (14%). A few pondered the morality of suicide (20%). They also left instructions (69%) regarding how to dispose of their property (29%) or their bodies (29%) or managing their affairs (29%). Some made requests to take care of others (25%) and occasionally advice was offered (22%). Some told police that this was a suicide (12%) or insisted on no attempts to resuscitate (8%). A few people used quotations from songs or books in their notes (10%).

Other feelings were mentioned in the notes. It is not surprising that some note writers felt tired (18%), lonely (16%), sad (16%), joyful (8%), hopeless (10%), worthless (10%), guilty (8%), and/or like a burden (14%) or failure (10%), as these feelings are relatively consistent with the need to escape. Only one or two people talked about feeling ambivalent, apathetic, or ashamed. For the most part, they were unwavering in the course of action that they had decided upon. In fact, a few expressed relief. Unlike the anger that was present in so many suicides which were driven by interpersonal relationships, only a few individuals expressed feeling angry.

Even the suicidal acts are in stark contrast to those who were motivated by interpersonal relationships. In our research, those who killed themselves to escape pain were less likely to use violent means such as guns or knives than nonviolent means such as poison or hanging. Those who killed themselves for interpersonal reasons more often used violent means. Thirteen of these individuals killed themselves in front of another person; three committed murder-suicide and two of the victims were not intimate partners. Guns were much less frequently used (45%) and more victims died by asphyxia (28%) or toxic substances (22%). Asphyxia was three times more likely to be from ligature or hanging than from carbon monoxide. Hanging is certainly not as impulsive as using a firearm and sends a very different message. Consider the case of Zack.

After high school, Zack started going to rave parties and experimented with LSD and ecstasy. Then he met Lisa. They fell in love, married and had two children. However, Zack could not give up his raves, and eventually he and Lisa split up. Zack also could not hold a job, because he always showed up late for work. When his car broke down he bought a used car from a friend but after weeks still had not paid him the money. Eventually, the friend went to the police and Zack was issued a summons. Zack wrote notes to his family and his new girlfriend, then asked a neighbor to give her the package of notes. He returned home, used a ladder to secure a rope over the rafter in his living room, tied a noose around his neck, put duct tape over his mouth, and kicked the ladder out from under him. When his girlfriend received the package she called the police.

Presumably Zack covered his mouth so no one would hear him struggling or perhaps so no one would come to his aid. However, it may also have been symbolic as to how Zack felt during the last years of his life, silenced by his problems and life itself. Certainly, for some children and adolescents, like Jordan, hanging may be the most readily available option, but for most people in this group, many other options existed. Perhaps they wanted to feel life slip away from them, again symbolically representing what it has felt like over the course of time. Maybe, like Jim, who was described at the beginning of the chapter, they wanted to feel the pain in death, the way they felt it in life.

Overall, individuals who killed themselves to escape multiple problems felt suicide was the only solution. Some feared where the future would lead them; others felt life had simply become too exhausting. In the words of one victim, “I’m just so tired, tired of the pain and just tired of the struggle. Every day I go out and pretend, I pretend nothing is wrong when deep down all I want to do is leave.”

Suicidal action can be a seasonal affliction. A popular perception is that people are more likely to commit suicide on holidays like Thanksgiving and Christmas (Jamieson, Jamieson, & Romer, 2003). A number of studies have addressed the question of seasonality in suicide, but one study focused on the differences between violent and nonviolent suicide. Maes, Cosyns, Meltzer, De Meyer, and Peeters (1993) found that seasonality was present in violent but not in nonviolent suicide. The number of violent suicides increased with age and was more prominent in men. According to the study, “The violent suicide chronograms of younger and elderly persons were quite distinct in the occurrence of peaks in March–April and August, respectively, and lows in December–January” (Maes et al., 1993, p. 1380). In our group, 31 people (12%) committed suicide in June, while 14 people, or 5%, died in December. Many people killed themselves late in the month, near the 20th (7%). Forty-three (17%) killed themselves on Wednesday.

The notes often reflect no sense of season or time. It is as if the cyclical rhythms of life that are so often marked by holidays followed by ordinary days have blurred into one form of time, eternal misery. Each day, no matter what day, was one faced with trepidation. “I cannot go on with this awful dread that fills each day,” one man wrote mournfully. “I have lost all will to live. I have lost all the elements needed to survive in work, love and life. I am so sorry for what this will do to my most wonderful children to which I am so blessed and my sister who has been great.” He died in early September. One 43-year-old woman suffering from diabetes and psychological pain drove her sports car, without braking, into a tree. She left a note that said, “I have given up on love, trust, faith & hope & dreams. There really is no such thing anymore & that’s sad. Im certainly not worth any tears but I doubt if anyone is sad anyway. So I guess that’s it.” She died in mid-September. A man went to his storage shed, full of the stuff of his life. In his note, he said material possessions never meant much to him, but events unfolded that were going to result in him losing everything. “If I don’t do this I see nothing but jail, misery & a slow painful death for the remainder of my life….Don’t be sad for now I am released…I’ve been carrying a big ball of guilt, shame, embarrassment hopelessness and worthlessness in my gut.” He hanged himself in mid-December. In none of these cases was there a mention of the time of year. The days of pain were ongoing, unending sameness.

Escaping From Psychological Pain

Virginia had struggled with depression for most of her life. When she met Bill she thought he would be her knight in shining armor. They married when she was 23 years old and had four children during the first decade of their marriage. Virginia did not realize until after they were married that Bill could not control his drinking. When Virginia quit her job to take care of the children, it increased the strain on both their finances and their marriage. Bill became verbally abusive and Virginia, who had already been taking medications for her depression, became anxious as well. Finally, she took the children and left Bill. She found single parenting difficult, but not as difficult as living with Bill. Virginia relied on her mother to help her with the children, but when the children were teenagers her mother suffered a stroke and died. Virginia’s depression worsened, and she began seeing a therapist.

After her family was raised, Virginia rented a small apartment and continued to work. She was a political activist and had even published a book, but these accomplishments did not assuage her psychological pain. She told her friends and co-workers that she had begun dating again and that she and her boyfriend were moving in together. However, no one ever met her boyfriend and some even questioned his existence. As the date of their cohabitation neared, Virginia told friends and co-workers that her boyfriend had been called away because of a family emergency. Shortly after that, she wrote notes to her family, drove to a park, and took an overdose of medications. In one note she said, “I fought the depression & anxiety since the 70’s. I just don’t want to deal with this anymore. I’m tired. Even as a child I’ve thought about not living. That may be hard to believe but it’s true.”

Life was crashing down on a number of different fronts for Jim, Ed, and Christy, who were described in the previous section. For individuals who commit suicide to escape psychological problems, one main source of distress exists, their mental illnesses. Like Virginia, most of the people in this category struggled with mental illness for a very long time. Although the average was 43, ages ranged from 12 to 82 years old, with over 70% under 50. The three youngest people in the sample were 12, 13, and 14 years old, and they were all diagnosed with bipolar disorder. Virginia thought about dying when she was a child; these children acted. Others talked about having feelings of wanting to die since they were children. One man said, “…but I still felt in my heart this was my fate because no one dies unless its ur time too…It was my fate callen now I understand why I was thinking about death when I was a little kid. Now I understand why I felt out of place as a kid when I felt weird some times about life because I was completly lost and was suppose to stay this way my whole life now I no why I felt this way and thought this way it was the shadows death.”

This group had 208 people, making it the second largest subcategory within escape. Similar to other groups, most of these individuals were Caucasian (88%), but this is the first group where the gap between the percentage of men (68%) and women is not as large. Women are approximately twice as likely as men to be depressed, and depression is the most prevalent diagnosis among those who commit suicide (Mayo Clinic, 2016). This is the first group where the number of men and women leaving notes was equal.

Twenty-four individuals left notes, which represented 12% of the group. For the most part, the notes were short and to the point. The majority left one note (75%) and they were under 150 words long (58%). They generally mentioned their struggles and professed their love for others (75%) and some said they felt loved by others (17%). They mentioned parents (33%), children (29%), partners (17%), other family (21%), siblings (13%), and friends (8%). Most had a specific addressee (67%) and were signed (58%). Overall, the victims’ thoughts were organized (88%), and very little evidence of tunnel vision (8%) or dichotomous thinking (4%) appeared.

The percentages of people who provided a justification for their actions is almost the same as in the escape multiple group (71%) and so is the percentage who asked for forgiveness (33%). Generally, they asked for forgiveness from God. One woman’s entire note read,

Another note read, “I just can’t go on anymore. I’ve thought about this for a very long time. But now I feel I can follow through. I just hope God can forgive me. I’ve been wanting to go home for a very long time.”

In comparison to the escape multiple group, fewer felt a need to apologize to specific individuals (25% vs 47%), offer general apologies (25% vs 33%), absolve others from blame (21% vs 24%) or blame others (8% vs 18%). There really was not anyone to blame and nothing for which to apologize, since they had an illness that they could not control.

Other than their psychological issues, they had few other identified problems. In general, they were not in legal (4%) or financial trouble (7%) and only one identified as having job problems while none had school problems. Ten percent of note writers in this group mentioned legal trouble in their notes, while 15% mentioned financial issues. Whereas almost half of the escape multiple group were dealing with interpersonal problems, only 29% of this group were having these issues, and there were very few (3) reports of domestic violence. Only one person talked about interpersonal abuse in her note. Even the percentage of physical illness (26%) was approximately half that of the escape multiple group. For these individuals, it was all about the pain of their mental illnesses.

Although the majority of individuals were depressed (61%), 15% had multiple diagnoses, 11% had bipolar disorder, 6% had schizophrenia, and for the rest the actual mental illness was not specified in the report. Some of the victims with mental illness had made previous suicide attempts (37%) or threats (25%) and had suicidal ideation (25%). It is not uncommon among people with mental illness to use substances frequently to self-medicate, and almost a fourth had problems with substance abuse (Bolton, Robinson, & Sareen, 2009).

No overwhelming themes appeared in their notes other than the need to escape (46%) and acknowledgment of their psychological pain (46%). One man who had struggled with lifelong mental illness and then separated from his wife described his pain as follows, “There is an emptiness, a hurt, pain!!! I can’t describe, I don’t have the word to explain, agony-rip, tear my flesh, HURT, HURT. Forgive me.” No one talked about physical pain, although some talked about unspecified pain (13%). Over one-fourth (29%) mentioned interpersonal issues and 33% talked of God, the afterlife (17%) or the morality of suicide (17%). Three thought suicide was immoral but discussed reuniting with the living after they died. One imagined watching over his loved ones. Interestingly, two out of ten of the women who wrote notes were retired surgical nurses.

When considering how short these notes were, and that most everyone mentioned love for others and almost half talked about the need to escape, the remaining content was sparse and not consistent across notes. A few of the note writers said that life was not worth living or that they felt like a failure or that they were lonely. Only one or two people mentioned feeling tired, guilty, shame, burdensome, hopeless, worthless, ambivalent, relieved, angry, or joyous. One person discussed being discriminated against. No one said they felt apathetic, talked about dissatisfaction with his/her body image, a recent death or having a disability.

When they left instructions (50%) they talked about taking care of others (25%), managing property (17%) or other affairs (13%), or disposal of the body (4%). When they gave advice (33%) it was generally short and simple, such as “U got to stay strong and learn quick or U die so be smart about every move u make.” Virginia told her son to “Stay the way you are.”

The methods that these individuals used to kill themselves were very similar to those used when individuals were motivated to escape multiple problems. Guns were only slightly more predominant (39%) than asphyxia (28%) and overdose (25%). Those who asphyxiated were three times more likely to die by hanging than by carbon monoxide. Most of the suicides occurred at home (82%) and only 13% were reported to have been using substances prior to their suicides. The most prevalent days of the week were Monday or Friday (19%) and the least prevalent was Wednesday (10%). Six percent killed themselves in front of someone, and there was no murder-suicide.

At least two of the women who wrote notes, including Virginia, had been lying to friends and relatives about major issues in their lives. After her death, it was confirmed that Virginia had been lying about her relationship status. One woman in her late twenties was lying to her relatives about having cancer. She had told her family and boyfriend that she had cancer, yet it was determined that this was a fabrication. All her loved ones remarked that she was very secretive about her health matters. In her note to her parents she wrote,

In her mind, her suicide was something she was doing for herself.

In fact, in some notes the note writer seemed to think that the impending suicide was just one more thing in her day. Jessica, 57, had struggled with depression her whole life. When her husband went out to a movie, she wrote a note, took an overdose of her medications, then lay down on her bed clutching a crucifix to her chest. When her husband came home he found her in that position. The first part of her note read, “Pete Warwick wants you to work tomorrow.” The font for the first part of the note is much larger, suggesting she may have written it earlier before the medications took effect. Then in the second part she wrote, “I love you with all my heart forever and Trish & Carly too but I can’t go backward again. I can’t make it through. God forgive me. I love you forever and always Jessica I’m sorry I failed you.” It is almost as if this was just a routine part of her day. Did she write the first part and then decide to kill herself or did she know she was going to kill herself when she wrote it? If she knew, it is almost as if she had no awareness that her husband would likely not be working the next day because his wife had just died. Or maybe she thought her death would not be important enough to keep him from work.

The prevailing sense in these notes is that the note writer is done with life and has made an indisputable decision to die. When Harry turned 65 years old he retired from his trucking job and had a lot of free time. Despite the fact that he was in Gamblers Anonymous, and had always struggled with his addiction to gambling, he decided to try his luck once more. In three months, he had gambled away $225,000. He wrote a letter to his friend who was the executrix of his will and told her of his intentions. The note to her was mainly instructions but he also said, “I have been so depressed for so long I really feel no need or want, to go on.” Enclosed with the note was a second note that Harry wrote to his dog apologizing for abandoning him and wishing him well. When she received the letter she called police, and they found Harry dead from a gunshot wound to the head. It is difficult to determine if Harry’s gambling problem led to his depression or his depression led him to gamble, but the end result was the same.

In short, the notes and actions of people in this group are unambiguous. They had simply had enough of life and wanted to die to escape the psychological pain. Some had received interventions and some had not. Others, like Harry, thought they had put their demons behind them, but they had not. They could never envision a time when they would have control over their own lives. As one person said, “This was my fate to be lost my whole life and die young… I never had control of my life so I wanted to have control of my death…I picked this date months before believe me it was hard to hold on this long.”

In November 2012, Christine O’Hagan attempted to kill herself but was interrupted when her daughter called home (O’Hagan, 2014). Although she knew she needed help, she was afraid that in doing so she could lose her job or family and that she would be stigmatized for having a mental illness. She prayed that she would die. She said, “The pain had to stop. I’d been through some painful moments, but nothing was comparable. I survived skin cancer as a preteen and live with lupus. I gave birth without pain medicine or epidurals. I’ve been hurt emotionally and mentally and never felt anything like this before. So when my children left for school for the day, I called in sick to work then said what I thought would be a final prayer for peace.” After her attempt, Christine revealed that she was diagnosed with generalized anxiety disorder, major depression, and obsessive-compulsive disorder. She received the right combination of medications and therapy and, with the support of family and nonmedication strategies, such as exercise, she is doing well. When she thinks back she says, “Now, all these months later, I understand what I could and should have done differently. I could have asked for help. I should have reached out sooner. I might have recognized that what I was feeling was biological and not my fault. This was not a weakness or a character flaw.”

Christine’s story stresses both the importance of reaching out for help instead of becoming isolated and confronting the stigma associated with mental illness. In and of itself, a mental illness, and the loss of control associated with it, can be paralyzing. However, when no one is there to help or normalize the symptoms, it can be painful and terrifying as well. The fear and pain is compounded by the social stigma from having a mental illness. When someone is diagnosed with a physical illness, such as diabetes, a wealth of social support exists. Yet when someone receives a diagnosis of schizophrenia, even if people want to help, there is a general lack of knowledge as to how to help. This absence, or in some cases inaccurate knowledge, and the plethora of misinformation about mental illnesses which is communicated in the media and even in popular culture such as films, enhances the fear of people with mental illnesses. For example, after a recent spate of mass shootings, House Speaker Paul Ryan suggested legislation to increase funding for the care and treatment of mental illness. He stated, “One common denominator in these tragedies is mental illness” (Huetteman & Pérez-Peñadec, 2015, p. 1). Although the increase in funding for the prevention and treatment of mental illness is long overdue, it shifts the blame for mass killings onto those with a mental illness. The vast majority of those diagnosed with a mental illness are not violent, and not all those who shoot others have a diagnosis of mental illness (Swanson, McGinty, Fazel, & Mays, 2015). It is no wonder that those who suffer from mental illnesses fear “coming out” to friends and family. In his note, one person said, “… no amount of money or girls or friends or family or cars could have made me not crazy again….I had a mental problem or was crazy u Know That was killing me on the inside that’s why I gave up because like I said before I couldn’t win I allready lost. I couldn’t live with peoples ridicule anymore my own family laughing at me callen me crazy, That was killing me cuz I know I couldnt do nothing about it…I was’nt scarred to die so don’t worrie. I was more prepared For Death Than Life.” Given the pain of mental illness, and the stigma associated with it, it is clear why death becomes a preferable alternative.

Living with any mental illness can be difficult, but when psychosis is present, which can appear in people struggling with illnesses like bipolar disorder or schizophrenia or be induced by some drugs, it can be especially painful (Black, Winokur, & Nasrallah, 1988; Tarrier, Khan, Cater, & Picken, 2007). Tammy, who is discussed further in Chapter 7, Severe Mental Illness, suffered from auditory hallucinations. “I just can’t take it anymore the voices in my head R driving me crazy Ive had them sence last Ester Don’t let Casey do that to anyone else.” Some felt they were no longer in control of their actions. “I worry that the demons are trying to possess me. P. N. I can’t keep battling this.” Others believed that death was the only way to drive out the devil that lived inside. “I don’t want to live with the devin inside me. I don’t want to be set up after everything over. Please tell everyone the truth. I love you all.”

Escaping From Physical Pain

Louie and Marilyn had been married for 54 years and had two wonderful daughters. Shortly after his 78th birthday, he began having severe stomach pain and vomiting. They were shocked to learn that he was in stage four of pancreatic cancer. He began chemotherapy but the pain increased, and Louie became despondent. One morning Marilyn woke, showered, dressed and checked in on him. After she left the room, he wrote a brief note, placed the bathroom rug on his side of the bed so that he would not make a mess, then laid down on it. Marilyn was in the kitchen preparing breakfast when she heard a loud “bang” and found her husband in their bed with a gunshot wound to the head. He left a note that said, “I’m going crazy I hurt so bad, try to forgive me for taking my life. I know it’s not right, I’m pushed to the breaking edge…I love you.” Although Marilyn knew they owned a handgun she did not think her husband had the strength to retrieve it from the upstairs bedroom where it was kept.

Without a doubt, health concerns can have an impact on suicidal behavior (WHO, 2014). Individuals who killed themselves to escape physical illness (118 people) have their own unique characteristics. Like other groups, they were mostly males (88%) and white (97%), but they were older, with an average age of 68 and a range of 34–94. In fact, 88% were over 50 years old. Very few of the notes or investigators’ reports mentioned legal (<1%), financial (3%), job (0%) or interpersonal problems (4%), substance abuse (6%), or abusive relationships (<1%). Instead they all talked about physical illness and some note writers, like Louie, targeted the illness as the precipitant for the suicide.

Physical illness is a critical motivating factor for suicide (Shiratori et al., 2014). For example, suicide risk increases in the 90 days following a diagnosis of malignant cancer (Bolton, Walld, Chateau, Finlayson, & Sareen, 2015). Although some research has linked discharge from a psychiatric hospital to increased risk of suicide, the link between discharge from a general hospital and suicide is just beginning to be explored. Dougall et al. (2014) found that individuals who killed themselves were 3.1 times more likely to have been discharged from a general than a psychiatric hospital. Moreover, “higher percentages of people died by suicide 3, 6 and 12 months after last discharge from general than from psychiatric hospitals” (p. 267). Physical illness is recognized as a risk factor for suicide in older populations. Harwood, Hawton, Hope, Harriss, and Jacoby (2006) conducted psychological autopsy interviews relating to over 100 victims who were 60 years old or over. They found that the most frequent life problem associated with suicide, a contributory factor in almost two-thirds of cases, was physical illness. Pain contributed to the suicide in approximately one-fourth of their sample.

Many of the investigators’ reports and some notes discussed recent medical involvement such as a visit to the physician or a hospital admission. One 85-year-old man, whose lung cancer had metastasized to his bones, had just had a portion of his femur removed. In his note to his children, he wrote, “Carrie, Sissy, Nelly, it does not look very good for the outlook of my leg the way it is healing. Yesterday I had a spell of coughing of my chest. Not so bad now but I’m having a problem of breathing. I also have a problem of eating. Nothing taste right. Hard to eat enough to keep me going. I do not like the way things are. I therefore am thinking of checking out. I hope that you fellows will forgive me. I hope that god will forgive me. Dad.” He later added, “5:30 PM I’m so sorry fellows, I think I have lived long enough.” He left notes throughout the house informing his children how to settle his affairs and dispose of his property and then shot himself while sitting in his wheelchair.

Other note writers did not discuss a recent admission but were dreading a future admission. Sam was only 34 years old but was obese and a heavy smoker. After suffering numerous painful gallbladder attacks, he had his gallbladder removed. Unfortunately, he developed a hernia and had three more surgeries. He became depressed over the continuing pain and the need for yet another surgery. He wrote a note to his father and said, “I love you, and I am sorry…Truly. Please understand, I am in pain, Great [unintelligible] pysyically & emotionally—I don’t want any more surgeries or pain.” Then, he overdosed on his pain medications.

The vast majority of individuals who were trying to escape physical illness killed themselves at home (89%), using guns (80%). When we could determine where they were living prior to their deaths, it was fairly evenly split between living alone (34%) or living with a spouse/partner (37%), while a few were living with adult children. None of them committed murder-suicide and only 6% killed themselves in front of someone else. A small percentage were reported to have been using substances prior to their deaths (6%).

Some people had expressed suicidal ideation (15%) or made threats (19%) but only 6% were reported to have made previous attempts. It is likely there were few attempts because prior to their diagnoses, these individuals had been contented with their lives and were not trying to escape from anything. Approximately one-third (34%) of the investigators’ reports spoke of an additional psychological illness, usually depression (93%). However, for most of these people, the source of depression was their physical illness. For example, Anthony suffered a stroke when he was 76 and after that he had difficulty sleeping and eating. In a year he had lost over 70 pounds and could only tolerate eating chicken. He was depressed about his physical illness and told his wife that he did not know how much longer he could take it. In the middle of the night, he went outside their house and shot himself by their garbage cans. His note read, “Maggie Sweetheart-My Nerves have snapped—Never thought I would do this but I can’t take any more of this punishment!! I see no help in getting well…Love you dearly and everybody else.” The suicide was directly a result of the physical illness. Although depression may mediate the link between physical illness and suicide, even when mental illness is factored out, still an increased risk of suicide exists.

In a small subset of cases, generally among the older victims, physical illness resulted in a loss of independence and triggered considerations about future housing options. For example, Gordon was 75 years old and had suffered from severe chronic obstructive pulmonary disease (COPD) for several years. He had just spent a week in the hospital and was settling back into his home when his sister suggested that he consider moving into assisted living. He told her he would rather die than move into assisted living. Ten days after his discharge, he sat down in his favorite living room chair and shot himself in the center of his chest. His sister had asked a relative to remove the gun from his home almost a year before Gordon took his life. Harwood et al. (2006) also found that the possibility of moving into an assisted care facility, or with adult children, precipitated suicide in their sample.

Gordon’s story is emblematic of two problems family and friends may have when confronting a situation like this. “I’d rather die” can be a colloquial expression; many more people say it than carry out a suicide. Recognizing what patients are saying when they assess their own pain and understanding the impact of severe pain on desire for death, from the patients’ own words, can provide a framework for a clinician to intervene, though it may be more difficult for a family member or friend (Coyle, 2004). It can be awkward raising the issue of getting psychological help. Likewise, seeking to remove firearms or other means of killing oneself from a home can be a hard discussion to have. Gordon’s sister recognized the danger of having weapons in the home, but she did not act decisively enough to remove them. Perhaps she could not under the circumstances. Organizations like the National Alliance on Mental Illness (NAMI) sometimes offer classes to teach communication or offer other services to facilitate conversations with people suffering from mental illnesses, including depression brought on by circumstances.

Although no large differences in the day of death were apparent, more people killed themselves on Saturday than any other day (19%), unlike the prevalence of Monday for other groups. Perhaps this is related to the lack of medical care available on the weekends. Additionally, more deaths occurred in the spring (32%), particularly April (14%). The fewest deaths occurred in the fall (19%). It may be the contrast between the renewal of life in the spring and their continuing pain which precipitates a desire to die.

Not only did the demographics and characteristics associated with these suicides differ from those motivated by interpersonal reasons, but so did the notes they left. A total of 17 people, or 14%, left suicide notes. This is typical for our overall sample, but it is much less than those motivated by lost love and much greater than from abusive relationships. In general, the notes are less dramatic than those written for interpersonal reasons. For instance, not one person talked about feeling lonely, relieved, angry, ashamed, apathetic, or worthless. No one discussed feeling like a failure, forgiving oneself or others, watching over others, or having problems in their relationships. Only one person mentioned feeling guilty or ambivalent or sad. There were no quotations or poems and no humor. However, over two-thirds mentioned their love for others. A little over one-third showed thought constriction; they simply saw no other way out and they provided justification for their actions (71%). Most did not mention an afterlife, although some (29%) mentioned God.

The notes were short (71% were under 150 words), and most wrote only one note (82%). The focus of the notes was more on escaping (59%), physical pain (41%), disability (35%), medications (18%), unspecified pain (29%), psychological pain (12%), and that life was not worth living (24%). One entire note read, “Kelly, Phone 000-0000 I couldn’t stand the pain any longer. Thanks for all you done for me. Love, Brandon.” This man had colon cancer and had recently had a colostomy which left him with increased pain and discomfort.

The pattern that emerges here is in sharp contrast to those who killed themselves for interpersonal reasons. Aside from some basic demographics, such as gender, very few similarities exist. Their notes are short, simple, and straightforward, with no assignment of blame. They are older individuals who are not experiencing secondary problems such as legal issues; rather the primary problem is their declining health and its impact on their quality of life. Their interpersonal relationships are good, with no sign of revenge. When friends and family are mentioned in notes, the expressions are full of love, not bitterness, and frequent requests for forgiveness appear. They also differ from those who are attempting to escape from legal and financial problems.

Escaping From Legal and Financial Crises

Conclusions

The majority of people in our sample were attempting to escape. For some, that escape was from actual physical or psychological pain. For others, the escape was related to circumstances which they believed were too difficult to ever overcome. The unknown of death was preferable to the knowns of life.

Many of these people were facing their circumstances alone. Sometimes this was by design but other times they had alienated friends and family. Also, some individuals feared reaching out, especially those struggling with a mental illness, due to the possible impact it would have on their lives. No doubt there were others, such as those having legal or financial difficulties, who were too humiliated to share their circumstances with others. Without social support, it is easy to develop tunnel vision and only see one solution to problems. For a moment, imagine that your doctor just gave you some bad news about your health but you had no one with whom you felt you could share this news. Furthermore, you could not process treatment options with anyone other than your health care providers and no one was there to help with caretaking or assistance. In other words, you are not only being confronted with this upsetting news, but you also have to deal with how alone you feel in life. Suicide becomes an option not only for the escape it provides, but also for the relief. You no longer have to worry about solutions to your problems or your aloneness. This does not mean all of these individuals were alone, but they felt alone and they wanted to escape. Escape means to break free from confinement or control. These individuals felt they no longer had control over their lives but believed by killing themselves they would gain control. The key to successful prevention and intervention lies in finding other ways to give them back control.