Night Falls Fast: Understanding Suicide

By Kay Redfield Jamison

New York: Alfred A. Knopf 1999, 436.

It is difficult to comment on Night Pails Fast without making reference to The Savage God. A Study of Suicide, the 1971 classic by the English poet and writer A. Alvarez (W.W. Norton & Company Inc., New York, 1990; first published by Penguin Books, London, 1971).

Both books are their author's overtly stated effort to come to grips with a topic that is of more than mere academic interest to them. Indeed, it is the very fact that each has had costly personal encounters with suicide that lends their books an intimate tone and genuine sense of credibility.

The books' similarities are not only of content; in addition to their understanding of self-destruction, Jamison and Alvarez share a deep-seated passion for words and rely heavily on literature as instrumental to their task. But whereas The Savage God is explicitly literary--suicide through the historical lens of literature--Night Fails Fast makes a more sparing and incidental use of written and other art forms.

The differences between the books--the ratio of literary to scientific references foremost among these--tell as much about their authors' disparate styles and professional backgrounds as of progress in understanding suicide that has transpired in the 3 decades between the books' publication dates.

Alvarez's review of the science behind suicide was mostly circumscribed to basic demographics and theory largely centered on [acute{E}]mile Durkheim's sociological work and the psychoanalytic conceptualizations stemming from Freud's seminal Mourning and Melancholia.

By contrast, Jamison's bibliography is an encyclopedic compilation of the vast literature on suicide and a display of the no-stone-left-unturned erudition that contributed to the making of her (and Frederick Goodwyn's) Manic-Depressive Illness into a classic in the field. The strength of the bibliography is highlighted all the more by being relegated to the last hundred pages of the book, where it sits understated yet accessible, rather than intersperse d as the mountain of intrusive footnotes that one might expect of such a scholarly review.

In Alvarez's book, theory is but the brief introduction to the literary lives that unfold in the longer sections that follow. It is telling that his chapter on theory was tided "The Closed World of Suicide."

Not only was suicide closed to the scientific understanding of more recent years, but in 1970s England, the act itself was cloaked to an even greater extent than today in a veil of shame and stigmatization (and its attempt, to add insult to injury, considered a prosecutable offense).Alvarez admits to his own failed suicide attempt only in his book's epilogue, in contrast to Jamison's opening disclosure.

The distinction is once again a telling one: whereas Alvarez sees his suicide as the final outcome of a protracted period of strain, Jamison understands her own as the natural (and no less painfull) consequence of her underlying manic-depressive illness. Indeed, the shift in focus from a stress to a mental illness conceptualization of suicide is one of the major changes that the field has seen in the dec ades between the books, and one with important implications for prevention and treatment.

This is particularly apparent in Jamison's summary of the criticisms leveled against many school-based suicide prevention curricula: that they "normalize" suicidal ideation by deemphasizing the role of psychiatric disorders, such as depression and substance abuse, and seeming to imply that given enough stressors, anyone might become suicidal. In contrast, she supports the view that a more effective intervention strategy is one that seeks to identify and treat psychiatric illness, especially among adolescents and young adults.

Night Falls Fast is perhaps above all a book about the disproportionate toll that suicide exacts among the young. Although elderly, white, alcoholic widowers are of course at highest risk, introductory lectures and media sound bites have perhaps less consistently reminded us that suicide is the third leading cause of mortality in young people, second among college students.

Night Falls Fast invites and urges us to reframe suicide as a public health concern of epidemic proportions and to address it urgently as such. The book is divided into 4 sections that lay the groundwork for such an approach. In the first section, the magnitude of the problem is laid out, with graphs dramatically conveying the point. Only tuberculosis and accidents kill more young people worldwide than does suicide; suicide killed almost 15,000 more young American men than AIDS in the decade starting in 1987, and mortality by AIDS has sharply declined since, whereas suicide rates have remained constant.

Although Jamison discusses in detai l the high rates of suicidal ideation and attempts reported by adolescents in surveys such as those of the Centers for Disease Control and Prevention, what distinctive features of adolescence render them especially vulnerable to contemplating and completing suicide remains a compelling question for our field.

The second and third sections, respectively, deal with psychopathology and biology and tease apart the myriad factors within the environmental-genetic interplay that can culminate in suicide. Among the many covered topics are the contributions of family genetics, prenatal insults, underlying psychopathology, neurochemistry, gender, adverse life events, and even diet (recent studies have shown an association between low cholesterol and certain polyunsaturated fatty acid levels with attempted and completed suicide).

"Building Against Death," the book's final section, reminds us that suicide should be construed as a preventable (though still largely unprevented) cause of death. Even if an individual suicide may still be impossible to predict or prevent, the identification, stabilization, and ongoing treatment of serious psychopathology has a clear impact on suicide rates, an effect that has most robustly been described for lithium in the treatment of manic-depressive illness among young adults.

The finding is far from an invitation to complacency: despite a deepening understanding of the pathways toward suicide and a much thicker bibliography on the topic accrued between The Savage God and Night Falls Fast, suicide remains a steady killer. In addition to raising our awareness and spurring us to professional action, Night Falls Fast lets us read beyond the statistics and the hard science.

By interspersing at the end of each of its sections the wrenching stories of individual suicides and personal details of her own life, Jamison has given us a book that does not view suicide's victims as the other, but rather as the all-too-human reflections of our own darkest selves.

Suicide's continued power to disturb and challenge us reflects the fact that it is the rare person who has not felt at moments the strong pull and seduction that it exerts on its victims, a fascination that Langston Hughes succinctly expressed in his Suicide's Note: "The calm,/Cool face of the river/Asked me for a kiss."

COPYRIGHT 2000 Lippincott/Williams & Wilkins

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