Leonardo Tondo: Brief History of Suicide in Western World
Janusz K. Rybakowski comment on Robert Goldney and Johan Schioldann’s comment
I would like to congratulate Leonardo Tondo for his excellent essay on the brief history of suicide in Western cultures. In his replay to Hector Warnes posted on October 24, he underlined a medical (psychiatric) approach to suicide which can be conceptualized as a result of a depressive state, especially with mixed features. Having said this, Leonardo indicates that such a condition could be highly preventable with pharmacological and psychological interventions. Corresponding with that view, the suicides of famous people with manic-depressive (bipolar) illness should be mentioned. A part of them took place on the day of the sudden switch from manic or hypomanic states into severe depressive ones.
The ancient historical example (not mentioned in Leonardo’s essay) of spectacular manic-depressive disorder ending in suicide can be found in the Iliad. One of its protagonists was Ajax the Great, next to Achilles the bravest warrior fighting in the Trojan War, son of Telamon – the king of Salamis. After awarding Odysseus with the armor of Achilles, whose body Ajax took from the battlefield, a state of mental disorder with sudden psychotic excitement, visual hallucinations, and aggressive behavior occurred in Ajax. In such a state Ajax wiped out a whole herd of rams, taking them for soldiers. After going into a frenzy, Ajax in a state of depression (in shame for what he had done) committed suicide. This story is the basis for Sophocles’ tragedy Ajax (Sofocles 2001).
According to a Hungarian expert on bipolar illness, Zoltan Rihmer, the type of bipolar II (with hypomania) could be even more susceptible to suicide than bipolar I (with full-blown manic episodes) or unipolar depression (Rihmer and Pestality 1999). From a medical point of view, it should therefore be advisable to treat not only manic but also hypomanic states for preventing such a sudden switch into depression. The suicide during a severe depression suddenly following the hypomanic state took probably place in an American writer of Polish origin, Jerzy Kosinski (1933-1991). It is not known whether there were such circumstances connected with suicides of such celebrities as Mark Rothko, Ernest Hemingway or Robin Williams.
In this context, the drug which can significantly decrease the risk of suicide should be mentioned, namely lithium. The first who observed such an effect was an eminent British psychopharmacologist, Alec Coppen (1923-2019). He followed-up 103 patients attending lithium clinic for 11 years and concluded that lithium reverses the excess mortality associated with mood disorders, mainly by preventing suicide (Coppen, Standish-Barry, Bailey et al., 1991). Shortly after this, the researchers assembled in the International Group for the Study of Lithium-treated Patients (IGSLI) analyzing 827 patients with bipolar and schizoaffective disorder given lithium treatment for more than six months observed that the mortality of these patients did not differ significantly from that of the general population (Müller-Oerlinghausen, Ahrens, Grof et al. 1992). Fifteen years later, a meta-analysis from Harvard University group (Leonardo was a part of it), including 45 papers containing data on suicides committed while taking lithium (on average for 1.5 years) and 34 papers registered suicides of persons not receiving lithium, showed that the risk of committing suicide was five times lower among patients taking lithium than those subjected to other forms of treatment (Baldessarini, Tondo, Davis et al. 2006). A more recent meta-analysis performed by Cipriani, Hawton, Stockton and Geddes (2013) with 6,674 patients concluded that lithium was significantly better than a placebo in reducing the number of suicides and deaths from any cause both in bipolar disorder and recurrent depression and superior to other mood-stabilizers or antidepressants.
Currently, the anti-suicidal effect of lithium in mood disorders is well documented and in many comparative papers, it has been shown that it is significantly greater than other mood stabilizing drugs. While being on lithium prevents suicide, its discontinuation significantly increases this risk. The anti-suicidal effect is not significantly correlated with the quality of prevention of mood recurrences by lithium, which points to the specificity of such an effect in reference to lithium (Lewitzka, Severus, Bauer et al., 2015). Therefore, the anti-suicidal effect of lithium should make an important element of personalized medicine connected with long-term lithium use. It seems reasonable to consider long-term lithium administration in each patient with a mood disorder with high suicidal risk. In so-called “excellent lithium responders”, lithium can be administered as monotherapy. In the remaining patients with a high suicidal risk, lithium should be a necessary component of combined mood-stabilizing therapy.
The song “Lithium” was written by the outstanding American rock musician Kurt Cobain (1967–1994), guitarist and vocalist of the group Nirvana. Cobain suffered from manic-depressive illness, was addicted to heroin and probably died a suicidal death. The title of the work refers to a therapeutic remedy that Cobain knew of but never tried using.
Astounding findings with lithium and suicide have been obtained in recent years, as the anti-suicidal effect of this drug has been demonstrated with its trace levels. In studies performed in Japan, Austria, Greece, and the USA, a negative correlation between suicides and lithium concentrations in drinking water was demonstrated (Ohgami, Terao, Shiotsuki et al. 2009; Kapusta, Mossaheb, Etzersdorfer et al. 2011; Giotakos, Nisianakis, Tsouvelas and Giakalou 2013; Blüml, Regier, Hlavin et al., 2013). These results may reactivate Cade’s speculation he made when administered lithium to manic patients, suggesting that lithium can be a trace element for mood disorders (Cade 1949). Furthermore, Japanese experiences could extend the issue of suicide beyond Western cultures.
Baldessarini RJ, Tondo L, Davis P, Pompili M, Goodwin FK, Hennen J. Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review. Bipolar Disord 2006; 8: 625-639.
Blüml V, Regier MD, Hlavin G, Rockett IR, König F, Vyssoki B, Bschor T, Kapusta ND. Lithium in the public water supply and suicide mortality in Texas. J Psychiatr Res 2013; 47: 407-411.
Cade JFK. Lithium salts in the treatment of psychotic excitement. Med J Aust, 1949; 36:349-52.
Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. Br Med J 2013; 346:f3646.
Coppen A, Standish-Barry H, Bailey J, Houston G, Silcocks P, Hermon C. Does lithium reduce the mortality of recurrent mood disorders? J Affect Disord 1991; 23:1-7.
Giotakos O, Nisianakis P, Tsouvelas G, Giakalou VV. Lithium in the public water supply and suicide mortality in Greece. Biol Trace Elem Res 2013; 156:376-99.
Kapusta ND, Mossaheb N, Etzersdorfer E, Hlavin G, Thau K, Willeit M, Praschak-Rieder N, Sonneck G, Leithner-Dziubas K. Lithium in drinking water and suicide mortality. Br J Psychiatry 2011; 198:346-50.
Lewitzka U, Severus E, Bauer R, Ritter P, Müller-Oerlinghausen B, Bauer M. The suicide prevention effect of lithium: more than 20 years of evidence-a narrative review. Int J Bipolar Disord 2015; 3:32.
Müller-Oerlinghausen B, Ahrens B, Grof E, Grof P, Lenz G, Schou M, Simhandl C, Thau K, Volk J, Wolf R, et al. The effect of long-term lithium treatment on the mortality of patients with manic-depressive and schizoaffective illness. Acta Psychiatr Scand 1992; 86:218-22.
Ohgami H, Terao T, Shiotsuki I, Ishii N, Iwata N. Lithium levels in drinking water and risk of suicide. Br J Psychiatry 2009; 195:464-5.
Rihmer Z, Pestality P. Bipolar II disorder and suicidal behavior. Psychiatric Clinic of North America 1999; 22:667-73.
Sophocles. Ajax. Cambridge University Press, Cambridge, 2001.
July 30, 2020