What suicide notes teach us about experiences with mental illness

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By Sean O’Malley

Can the study of suicide notes help clinicians in their efforts to prevent suicide? That is the premise of a new study by the Centre for Addiction and Mental Health (CAMH) and Sunnybrook Health Sciences Centre, published in the Canadian Journal of Psychiatry.

The unique study examined 1,565 cases of suicide, identified through the Office of the Chief Coroner of Ontario, which occurred between 2003 and 2009.  In approximately one-third of those cases, a suicide note was referenced, and in 290 cases a copy or transcription was included in the file. Within that group, the study authors focused on a subset of 36 suicide notes that explicitly referenced mental illness and/or mental health care.

“By investigating suicide notes, we have an opportunity to improve our understanding of the mind-set of people in the moments prior to their suicide deaths. The hope is that we can use this information to understand patterns of thinking that contribute to suicide. These patterns can be targets of treatment in those at risk,” says senior author Dr. Juveria Zaheer, a Clinician Scientist in CAMH’s Institute for Mental Health Policy Research.

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Within the notes, the authors found three primary themes that could improve the identification and treatment of those with mental illness who are at risk for suicide.

Feelings of control and powerlessness

Many people who died by suicide felt that they had no control of their mental illness and its impact on their lives.  Others felt that they maintained control over their lives, but were angry at themselves for being unable to change the trajectory of their illness.

Seeing their situation as a battle between the ‘real self’ and mental illness

Several writers framed mental illness as an opponent that must be “fought,” which seemed to use up valuable mental and emotional resources. They perceived the struggle as a “losing battle,” leading to feelings of exhaustion.

Experiences of mental health treatment that lead to hopelessness and self-blame

In over half of the suicide notes, the writers referred to previous mental health treatment.  While some expressed a sense of hopelessness, feeling that there was nothing that could be done to help them get better, others blamed themselves for not responding positively to treatment. In the context of severe depression and other mental illness, it can be difficult for patients to maintain hope that their condition will improve.

The authors stress that mental illness is treatable and that all people who are affected deserve to have timely access to high quality treatment. One of the implications for clinicians in assessing the risk of suicide is the importance of understanding the different ways their patients interpret their mental illness. By understanding the inner thoughts of a person prior to dying by suicide, there are obvious clinical implications for this research.

“It is very important for clinicians to talk to their patients about their thoughts and beliefs about having a mental illness and going through mental health care,” says lead author Dr. Zainab Furqan, a psychiatry resident at the University of Toronto. The authors say clinicians should make a conscious effort to identify feelings of helplessness or a sense of hopelessness in the context of a depression, creating an opportunity for interventions that may reduce the likelihood of suicide.

Sean O’Malley works in Media Relations at The Centre for Addiction and Mental Health.