From the Editor

Many people didn’t write one. But some did. The notes were usually short, typically only 600 words or so, and were often handwritten. Some talked about their illness; others didn’t.

What lessons can we learn from these suicide notes?

In the first selection, University of Toronto psychiatry resident Dr. Zainab Furqan and her co-authors consider notes left by those who suicided in a paper just published in The Canadian Journal of Psychiatry. They argue that we can learn from them, and offer clinical suggestions.


In the second selection, Columbia University’s Dr. Siddhartha Mukherjee argues that the obscure is relevant – he notes the decline and fall of the case report, and calls for its return.


Suicide Notes and Lessons Learned

“‘I Can’t Crack the Code’: What Suicide Notes Teach Us about Experiences with Mental Illness and Mental Health Care”

Zainab Furqan, Mark Sinyor, Ayal Schaffer, Paul Kurdyak, Juveria Zaheer

The Canadian Journal of Psychiatry, 16 July 2018 (Online First)

Suicide is one of the leading causes of premature death in Canada, with 4405 suicide deaths occurring in 2015. Epidemiological data and demographic characteristics of suicide attempters and decedents are often used to propose pathways to suicide. For example, empirically demonstrated risk factors for suicide, such as presence of mental disorders, past suicide attempts, and gender, have been used to substantiate the interpersonal theory of suicide. There is far less research, however, that explores the subjective experiences of people who die by suicide, yet this is critical clinical information that provides the subjective context of risk factors. Suicide notes are firsthand accounts that offer unique insight into the thought processes and emotional experiences of those who have died by suicide, information that is missed by quantitative analyses of suicide risk factors. Most studies examining suicide notes have used the notes to validate existing theories about suicide. Joiner and colleagues, for example, compared the notes from completed versus attempted suicides. They found that perceived burdernsomeness (a key component of the interpersonal theory of suicide) was correlated with completer versus attempter status. There is a small but growing body of literature that takes an inductive approach to the study suicide notes, allowing for the generation of new ideas and theories about suicide. Sanger and Veach investigated broad interpersonal themes within a large sample of suicide notes using grounded theory analysis, finding 7 themes that included ‘positive relationships,’ ‘explanations,’ and ‘concern for others.’

Suicide notes are left by approximately 15% to 38% of suicide decedents. Whether the findings from studies of suicide notes can be generalized to all those who die by suicide has been controversial, and the literature is inconsistent. While suicide notes are not necessarily representative of the experiences of all people who die by suicide, they are an important way of understanding the lived experiences of individuals who have died by suicide. This type of understanding can guide us in identifying targets for interventions, which can then be tested in more generalizable samples, with the intent of developing more effective and impactful strategies to decrease the burden of suicide.

Suicide notes can also provide insight into the role of mental illness, the feature that unites almost all people who die by suicide. Psychological autopsy studies show demonstrable mental disorders in at least 90% of suicide decedents. In a cluster analysis of suicide deaths in Toronto, males aged between 18 and 65 years, who had had depression or another major mental illness, accounted for the majority of suicide deaths.The epidemiological finding that mental disorders are nearly universally present in people who die by suicide has been well documented, but little is known about how mental illness is experienced by suicide decedents. A growing body of literature, however, suggests that illness identity and experience can have a significant impact on multiple psychiatric variables, including suicide. In a cluster analysis, for example, individuals who had insight into their illness and self-stigmatizing beliefs about their condition had lower levels of hope and self-esteem than those who did not hold self-stigmatizing beliefs.

To our knowledge, suicide notes have not been used to explore perspectives on illness identity and experience. Our study aims to bridge this gap in literature; through the study of suicide notes, we intended to explore the subjectivity of illness and treatment experiences, to enhance our understanding of pathways to suicide. Specifically, we sought to answer the following questions: ‘How are mental illness and mental health care experienced by suicide decedents who leave suicide notes?’ and ‘What role do these experiences play in their paths to suicide?’

csp-photoZainab Furqan

So begins an essay by Dr. Furqan et al.

Here’s what they did:

  • Working with the Office of the Chief Coroner for Ontario, they looked for suicide notes in the 1565 cases of suicide that were identified between 2003 and 2009, finding mention of 516 suicide notes, with 290 on file. Excluding several (language, illegibility), there were 252, which they used.
  • They took a constructivist grounded theory approach – an “acknowledgement of multiple subjective realities.” “All variants of grounded theory include the following strategies: a) simultaneous data collection and analysis, b) exploring emergent themes through early analysis, c) discovery of basic social processes, d) construction of abstract categories that explain these processes, e) sampling to refine the categories, and f) integration of categories into a theoretical framework.”
  • Using this approach, “a specific area of focus was not selected at the outset.” Instead, two of the investigators began coding independently, but with discussions, culminating in axial coding, which allowed categories to be created, until they reached thematic saturation (around 70 notes). All notes were then reviewed, but they collected a “purposeful sample” of 36 notes.
  • Categories were then used to develop themes. “Diagramming was used to propose links and connections between themes, to produce a descriptive narrative about the central phenomenon of the study…”
  • Composite quotations were developed.

Here’s what they found:

  • The authors of the suicide notes were male (54.3%), with a mean age of 42.3 years (with a SD of 14.5), and tended to handwrite that note (86.1%).
  • The authors describe various themes.
  • Negotiating Personal Agency in the Context of Mental Illness. “In total, we found that 16 people wrote about the degree to which they had control over their suffering in the context of mental illness.” Six saw illness as biological. Composite quote: “There is a problem in my brain. I think the chemistry is all wrong. No one could have fixed that.”
  • Conflict between Self and Illness. Five “described a sense of conflict between ‘self’ and ‘illness,’ using words likefightstruggle, and battle.” Composite quote: “I have fought against my thoughts, depression and alcohol constantly. I am too tired to keep going.”
  • Exhaustion. 12 “described a strong sense of fatigue associated with their path to suicide.” Composite quote: “I am exhausted from trying to fix everything. No one understands, not even doctors or my family, and I keep trying to get help. I feel like I’m a dead man walking for a long time. I’ve been judged by society and have been made to feel ashamed. I’m burned out and tired and trying to find some way to rest.”
  • Suicide as Exertion of Personal Autonomy. 14 “described the act of suicide as a purposeful choice or decision that highlighted their own autonomy.” Composite quote: “I am the person who decides what I’m going to do with my life. After being isolated and marginalized, I’m done with it all. This is my life and my decision.”
  • These themes were used to construct a model. See figure below.


A few thoughts:

  1. This is a good paper.
  1. The constructivist grounded theory approach is clever and interesting.
  1. Are there lessons to learn here? The authors think so:

Eliciting and addressing beliefs about mental illness and treatment.

“Our findings highlight the importance of exploring patients’ beliefs about their mental illness. Clinicians may want to consider specifically eliciting beliefs about agency and blame in the context of mental illness.” They note the role for a cognitive behavioural approach.

Addressing exhaustion. 

Our findings also suggest that narratives of self in conflict with illness may be exhausting and detrimental to some.” They note that “coherence of self” may be more important than dominating an illness.

Enhancing self-efficacy without suicidal behaviour. 

“Motivational interviewing, goal attainment, and problem-solving skills can be useful in helping individuals discover or create mechanisms of exercising agency with the purpose of altering their circumstances…”

  1. The number of suicide notes studied in detail was just 36 – a small sample. (For the record, the authors note: “While this is a small sample size, it is comparable to other in-depth studies of suicide notes.”)
  1. I’ll take a moment to note again that the first author is a resident. Wow.
  1. On a related note: Could computers and machine learning use suicide notes for suicide prevention? Cincinnati Children’s Hospital’s John Pestian argues that one day that may be possible. He explains his work in an NPR interview, which can be found here:


Case Reports and Medicine

“What Can Odd, Interesting Medical Case Studies Teach Us?”

Siddhartha Mukherjee

The New York Times Magazine, 17 July 2018

Late one evening in the medical library of the hospital where I work, I opened The Lancet, the medical journal, and came across a case report written by the neurologist-writer Oliver Sacks and colleagues. ‘In July 2011, a 52-year-old woman presented to our psychiatric outpatient clinic in The Hague with a lifelong history of seeing people’s faces change into dragonlike faces.’

Hooked, I continued: ‘She could perceive and recognize actual faces, but after several minutes, they turned black, grew long, pointy ears and a protruding snout and displayed a reptiloid skin and huge eyes in bright yellow, green, blue or red. She saw similar dragonlike faces drifting toward her many times a day from the walls, electrical sockets or the computer screen.’

I am not a neurologist. I don’t have a particular interest in abstruse hallucinations; nor, for that matter, did I happen to have a patient in the cancer wards afflicted by the sight of mythical creatures. But I could not stop reading.

1462302079479Siddhartha Mukherjee

So begins an essay by Dr. Siddhartha Mukherjee.

Dr. Mukherjee notes his fascination with the above case – which had remained a mystery despite the work-up. “It was as if Sacks lobbed the puzzle into the future for someone else to solve: In some distant time, he seemed to imply, another neurologist would read this story and find resonances with another case involving another patient and complete the circle of explanation. For now, though, there was no diagnosis, only description, observations without explanations.”

He makes several comments:

  • Case reports date back to the days of Hippocrates.
  • But they have fallen out of style, including in academic centres. “My professors in medical school ran clinical trials involving tens of thousands of patients, with no compunction about reducing humans to anonymous dots on graph paper.”
  • Major journals have stopped publishing case reports – the British Journal of Psychiatry did so in 2003.

He concludes:

As scientific journals prioritize randomized studies and mechanism-driven investigations — the ‘why’ over the ‘what’ — I miss the kind of writing that doctors like Sacks published. I miss the acuity of the observations, the scatter plots of symptoms that cannot be put into neat boxes, the vividness of description: ‘full moon at rising.’ I miss the textural idiosyncrasies of suffering that can be found only in real testimony. But most of all, I worry that unknown unknowns will go unwritten — that buried within such cases, there might have been a cosmos of inexplicable observations that might, in turn, have inspired new ways of thinking about human pathology.

A few thoughts:

  1. This is a beautifully written essay.
  1. Has medicine – including psychiatry – grown more sophisticated and data-driven, but perhaps less mysterious and inquisitive in the process?
  1. It should be noted that case reports served many roles, including in education – allowing residents to publish and stoke academic interest.
  1. Or is this whole discussion nostalgic but out of touch with the times? Case reports still exist, they have simply left our journals, and can be found on the Internet (on websites like Figure 1).


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.