The British Journal of Psychiatry (2006) 188: 229-230. doi: 10.1192/bjp.bp.104.007526
© 2006 The Royal College of Psychiatrists
Suicide now and then... an elusive comparison
Invited commentary on.. .Lifetime suicide rates in treated schizophrenia: 1875–1924 and 1994–1998 cohorts compared
TREVOR TURNER, MD, FRCPsych, Consultant Psychiatrist and Clinical Director
Department of Psychiatry, East Wing, Homerton University Hospital,
Homerton Row, London E9 6QR, UK.
Correspondence:
Tel: +44 (0)20 8510 8041; Fax: +44 (0)20 8510 8716; e-mail:
trevor.turner{at}elcmht.nhs.uk
Declaration of interest None.
See pp.
223–228, this
issue. 
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ABSTRACT
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Comparing suicide rates between Victorian and modern times, and the impact
of the asylum, should enable a useful historical perspective on how effective
our treatment approaches really are. Difficulties include clarifying the
‘social geography’, the underlying diagnoses, the reasons for
admission and the reliability of casebook data and follow-up arrangements.
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INTRODUCTION
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Comparing historical with current data might, on the face of it, seem
presumptuous, especially in the field of mental health. The diagnoses, the
methods of data collection and the different social and moral attitudes could
all be deemed potential confounding factors. However, among the forgotten
benefits of Victorian asylum care was the associated institutional insistence
on documentation. In England and Wales this was established by statute in the
1845 Asylums Act, which decreed not only that every local authority (e.g.
county or borough) should build a lunatic asylum for the pauper insane, if
they did not already have one, but also that proper case books should be kept.
The details of every patient who was brought into the asylum, including a full
admission and discharge register, had to be recorded, and there was a
mandatory (and inspected) frequency with which notes had to be made (i.e.
weekly, monthly, yearly), depending on the patient’s length of stay.
While being most obviously reminiscent of the modern National Health
Service insistence on documentation, such as the care programme approach
(CPA), the resulting case books have provided us with an extraordinary
resource. Although they vary in content, many of them survive in continuing
series (e.g. in local archives), and it is possible to obtain a detailed
picture of patient presentations, the language used to describe mental states,
and the procedures (e.g. of observation and treatment) that were employed. It
has also been possible to establish (for a number of the patients) the course
of illnesses, and reasonable and comparative diagnoses, based on modern
diagnostic criteria. The risks of retrospective diagnosis are well known, and
cases need to be carefully assessed, but even at the most parsimonious level
of comparison the similarities are robust enough to enable agreement
(Turner, 1992).
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RESPONSES TO SUICIDE
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Apart from studying diagnoses (and by and large the patients in Victorian
asylums suffered from very similar core symptoms to those treated today), the
reasons for admission, in social and family terms, and the outcomes of
treatment can also sometimes be compared with modern times. The study by Healy
et al (2006, this
issue) has followed in this tradition of comparative historical review by
looking at suicide rates. In particular, they have looked at contrasting
cohorts of patients deemed to have schizophrenia from a database of admissions
between 1875 and 1924, and from the notes of patients admitted to hospital
between 1994 and 1998. Since both of these cohorts come from the same area,
and were admitted to the same hospital, and there does not seem to have been
any significant change in the catchment size of the area population, it is not
unreasonable to consider that historically informative differences might be
found. In particular, the authors’ basic conclusion, that suicide rates
seem to be higher at the present time than they were 100 years ago (or
thereabouts), is bound to strike a chord among modern psychiatrists.
The lowering of suicide rates has become a key mental health target
(Department of Health, 1999),
and regular reports from the ongoing Confidential Inquiry into Suicide and
Homicide by People with Mental Illness
(Department of Health, 2001)
aim to clarify risk factors in this regard, in order (presumably) to improve
practice. Although there certainly are known risk periods for suicide –
for example, in the immediate aftermath of discharge from in-patient care
(Crawford, 2004) – it is
nevertheless true that most suicides today are not known to mental health
services. This also seems to strongly reflect the Victorian view of suicide in
relation to insanity: Tuke
(1892) quotes from a colleague
who considered that in only about 20% of cases was there ‘any proof that
the deceased had shown symptoms of mental disease, so far at least as his
friends were aware of the facts’. A modern review, entitled Suicide
in Victorian and Edwardian England
(Anderson, 1987), also showed
that rural rates were higher than urban ones (confounding the Durkheimian
thesis of ‘anomie’), and emphasised that any history of suicide
cannot be abstracted from its roots in social circumstances.
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SOCIAL ATTITUDES
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The most obvious problem therefore in Healy et al’s
comparison is deciding whether the two populations that were served by the
North Wales Asylum (that is, the late Victorian and the late 20th-century
populations) were truly similar in social terms. The population’s size
and age range may not reflect significant differences in transiency,
employment, social class and family stability, all of which are known risk
factors for attempted and completed suicide. Clarification of these would be
vital in any case, but given that Healy et al’s results
indicate that suicide rates in patients with schizophrenia are now 20-fold
higher – a disturbing level of difference – one must be sure that
the baseline population is truly similar. If their figures are carefully
boiled down, they show that in the course of 5 years the historical cohort had
1 suicide in 594 individuals, whereas the present-day cohort had 7 suicides in
133 individuals. Is the asylum genuinely providing a protective anti-suicidal
effect? Are these ‘pharmacological life events’? Or are we not
comparing like with like?
Certain other difficulties must be considered. For a start, is it possible
to compare the verdicts of suicide then and now? Although the legal rejection
of the suicide (banning burial in holy ground and even forfeiting all of his
or her goods) seems to have ‘gone into desuetude’ by the early
part of the 19th century (Tuke,
1892), it is not unreasonable to assume that attitudes to
self-killing, particularly in non-urban districts of Victorian Britain,
remained traditional. Protecting the family from the stigma of such a
pronouncement may have been a significant factor, and therefore the true
‘suicide rate’ may not bear comparison with modern, secular
pronouncements. Significant differences in suicide rates depending on the
religious background of countries in the 20th century have long been a problem
in suicide research, and ‘changing attitudes to suicide... were as
complex and variable as the very complicated social and cultural systems in
which they existed’ (MacDonald,
1995).
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WHAT WERE ASYLUMS FOR?
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With regard to retrospective diagnosis, although it is reasonable to accept
that those patients who were deemed to have a form of schizophrenia probably
did have an illness very similar to what we now call schizophrenia, we do not
know what proportion of such patients were admitted. Even today not all
patients with schizophrenia are admitted to hospital, particularly in
non-industrial countries, and admission depends on the attitudes of and burden
to the family, the nature of the symptoms and the degree of social disruption.
We know that there was a rising tide of admissions to the asylums between the
mid-19th and mid-20th centuries, and there has been considerable debate about
the cause of this. Edward Hare
(1983) suggested the
possibility that the rising numbers of patients with schizophrenia might have
been related to urbanisation and some form of low-grade infection, but most
other commentators (e.g. Scull,
1979) have suggested that this trend was more socially generated.
Once an asylum was available, people became gradually more used to putting
away their difficult relatives, and if asylums were cheaper than the workhouse
(as they became in the 1870s), the parish guardians would have actively
promoted their use. Asylum doctors had to admit whoever turned up with the
appropriate certificates, and discharge was a slow legal process.
In addition, the role of the asylum was highly structured, with up to 20%
of admissions considered to involve some form of suicide risk. In fact, if one
looks at the certificates that were used (i.e. the section forms), doctors
often regarded a suicidal tendency as something worth writing down in order to
ensure admission. Highly structured arrangements within the wards (e.g.
suicide cards) made the staff and hospitals extremely sensitive to a suicide
taking place, and woe betide the attendant, superintendent or responsible
guardians if suicide occurred within the asylum. Given this bureaucratic
stigma (and the likelihood of losing one’s job), and given the regular
rate of deaths in asylum (e.g. from a range of physical illnesses), is it
unreasonable to suggest that it was not in the asylum worker’s interests
to announce that any of their patients had killed themselves? We also do not
know whether suicides that occurred after discharge were actually recorded in
the asylum statistics, even though some patients were followed up. Again the
stigma attached to documentation of suicide may have affected this
procedure.
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CONCLUSIONS
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Overall, therefore, and especially in the vexed area of suicidal behaviour
(MacDonald, 1995), considerable
caution is required when reviewing historical comparisons. We may have
comparative illnesses (and the fascinating symptom similarity between then and
now is essential evidence for regarding schizophrenia as a consistent and
valid diagnosis), but the behaviours secondary to those illnesses will be
socially generated rather than ‘biological’. It is not as if today
we are living in a rising tide of suicide (rates have gone steadily down since
the 1970s), even though our attitudes are probably more secular and
non-avoidant of the term. Nevertheless, clinicians who are faced with the
modern, revolving-door, usually male, often drug-dependent and variably
insightful patient with schizophrenia may wonder what lessons are to be
learned from this paper. Can we re-introduce the good bits of asylum practice
into modern community care? Were some aspects of institutions in fact
genuinely therapeutic? How effective are modern medications in suicide
prevention (as opposed to symptom alleviation)? And should we be making more
use of the data – and lessons – of history when organising care
for people with severe mental illness?
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REFERENCES
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Anderson, O. (1987) Suicide in
Victorian and Edwardian England.Oxford: Oxford University
Press.Crawford, M. J. (2004) Suicide following
discharge from in-patient psychiatric care. Advances in Psychiatric
Treatment, 10, 434
–438.[Abstract/Free Full Text]
Department of Health (1999) National
Service Frameworks for Mental Health: Modern Standards and Service
Models. London: Department of Health.
Department of Health (2001) Safety
First: Five-Year Report of the Confidential Inquiry into Suicide and Homicide
by People with Mental Illness. London: Department of
Health.
Hare, E. (1983) Was insanity on the increase?
BMJ, 142, 439
–445.
Healy, D., Harris, M., Tranter, R., et al
(2006) Lifetime suicide rates in the course of treatment of
schizophrenia in North Wales: cohorts for 1875–1924 and 1994–1998.
British Journal of Psychiatry,
188, 223
–228.[Abstract/Free Full Text]
MacDonald, M. (1995) Suicidal behaviour –
social section. In A History of Clinical Psychiatry
(eds G. Berrios & R. Porter), pp. 625–632.
London: Athlone Press.
Scull, A. (1979) Museums of Madness:
The Social Organization of Insanity in Nineteenth-Century
England. London: Allen Lane.
Tuke, D. H. (ed.) (1892) A
Dictionary of Psychological Medicine. London: J & A
Churchill.
Turner, T. H. (1992) A Diagnostic A
Diagnostic Analysis ofthe of the Casebooks of Ticehurst House Asylum
1845–1890. Psychological Medicine Monograph Supplement 21.
Cambridge: Cambridge University Press.
Received for publication January 27, 2005.
Accepted for publication February 2, 2005.
Related articles in BJP:
- Highlights of this issue
- SUKHWINDER S. SHERGILL
BJP 2006 188: 199-a9.
[Full Text]
- Lifetime suicide rates in treated schizophrenia: 1875–1924 and 1994–1998 cohorts compared
- D. HEALY, M. HARRIS, R. TRANTER, P. GUTTING, R. AUSTIN, G. JONES-EDWARDS, and A. P. ROBERTS
BJP 2006 188: 223-228.
[Abstract]
[Full Text]
-
- PETER TYRER
BJP 2006 188: 300.
[Full Text]
TOP
ABSTRACT
INTRODUCTION
