Do countries with more mental illness have more suicides? At first glance, it seems as though the answer must be "yes". Although not all suicides are related to mental illness, unsurprisingly people with mental illness do have a much higher suicide rate than people without. So, all other things being equal, the rate of mental illness in a country should correlate with the suicide rate. Of course, all other things are not equal, and other factors might come into play such as the quality of mental health services. But it still seems as though there should be a correlation, albeit not a perfect one, between mental illness and suicide.
I decided to see whether or not there is such a correlation. The World Health Organization (WHO) provides the relevant data here. There have only ever been three studies attempting to measure rates of common mental illnesses internationally (1,2,3), and all three were run by the WHO. The WHO also collates national suicide rates (here) for most countries, although a few are missing. No-one seems to have published anything looking for a correlation between these two sets of numbers of before, or if they did, I've failed to find it.
So what's the story? Take a look -
In short, there's no correlation. The Pearson correlation (unweighted)r = 0.102, which is extremely low. As you can see, both mental illness and suicide rates vary greatly around the world, butthere's no relationship. Japan has the second highest suicide rate, but one of the lowest rates of mental illnesses. The USA has the highest rate of mental illness, but a fairly low suicide rate. Brazil has the second highest level of mental illness but the second lowest occurrence of suicide.
*
Some technical notes: Two of the three surveys, the ICPE (2000) and the WMHS (2004), sampled the whole population of each country. The other one, which was also the earliest, the PPGHC (1993), surveyed people attending family doctors. Because this is a slightly different approach, I used the ICPE and the WMHS for the plot above, although the results from the PPGHC are very similar (see below).
The ICPE sampled 7 countries and the WMHS sampled 14, but 4 countries were included in both surveys, so there's a total of 17 countries. I've used the mean of the ICPE and the WMHS for those 4 countries where we have data from both, for the rest I've used whichever is available. For the suicide rates, the WHO gives data for various different years, so I've used 2002, or the nearest available year, since this is between 2000 and 2004. For two countries, Lebanon and Nigeria, the WHO do not report suicide rates. For China, rates of mental illness are given in both Beijing and Shanghai.
The studies used structured diagnostic interviews to try to measure the percentage of people suffering from mental illness in the 12 months before the interview. As I've said previously, this -
attempts to study a random sample of the population of a certain country. In order to establish whether each person is mentally ill or not, they use structured diagnostic interviews. These consists in asking the subject a fixed ("structured") series of questions, and declaring them to have a certain mental disorder if they answer "Yes" to a given number of them.
In this case the structured question interview was called the CIDI and it used DSM-IV criteria. You can check it out here. Example question:
You mentioned having periods that lasted several days or longer when you felt sad, empty, or depressed most of the day. During episodes of this sort, did you ever feel discouraged about how things were going in your life? (YES, NO, DON’T KNOW, REFUSED)
*
The rates from the population surveys (ICPE & WMHS) don't correlate with suicide but they do correlate with the rates from the PPGHC survey of people attending family doctors. The association here is very strong, with a correlation r = 0.693. The only outlier is the US. This is despite the fact that a decade elapsed between the first survey (1993) and the other two (2000, 2004).
This is important because it shows that the mental illness surveys are measuring something about these countries, something which is stable over time. They're not just producing random junk results. But whatever they're measuring, it's not related to suicide.
*
What does this mean? You leave a comment and tell me. But here's my take. I've often expressed skepticism of population surveys and their (very high) estimates of mental illness, and of the dubious political conclusions certain people have tried to draw from them, but even so, I was surprised to find no correlation at all with suicide. I'd say that any meaningful measure of mental illness should correlate with suicide. These surveys, using the CIDI, don't, so to me they're not meaningful.
One thing to bear in mind about these numbers is that they deal with "common" mental illnesses like depression, substance abuse and anxiety. They leave out the most severe disorders such as schizophrenia. Also, people in psychiatric hospitals, in prison, and the homeless, will not have been included in the studies because they sample "households". That could be why there's no association with suicide, but if so then these surveys are missing a very important aspect of mental health. The surveys do seem to measure something, but I don't think it has much to do with mental illness. This is just a guess but I suspect they're measuring willingness to talk about your emotional life to strangers. At least stereotypically, the Chinese and the Japanese are known as more reserved in this regard than Brazilians and Americans. So it's no surprise that when you ask people a load of personal questions, the "rates of mental illness" seem to be lower in Japan than in America. This doesn't mean Americans are really more ill, just more open.
I've been talking about surveys looking at differences between countries, but if these are flawed, then so are surveys looking at just one country. For example, many studies have looked at mental illness in the USA using similar methods to these. But can we trust these methods bearing in mind that if you ask the same questions in, say, Belgium you get less than half the estimated rate despite it having double the number of suicides? Taken to its logical conclusion, maybe we know little about the prevalence of "common mental illness" anywhere. Sartorius N, Ustün TB, Costa e Silva JA, Goldberg D, Lecrubier Y, Ormel J, Von Korff M, & Wittchen HU (1993). An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on 'Psychological Problems in General Health Care'. Archives of general psychiatry, 50 (10), 819-24 PMID: 8215805
WHO (2000). Cross-national comparisons of the prevalences and correlates of mental disorders. WHO International Consortium in Psychiatric Epidemiology. Bulletin of the World Health Organization, 78 (4), 413-26 PMID: 10885160
Demyttenaere K, & et Al (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA, 291 (21), 2581-90 PMID: 15173149
Do countries with more mental illness have more suicides? At first glance, it seems as though the answer must be "yes". Although not all suicides are related to mental illness, unsurprisingly people with mental illness do have a much higher suicide rate than people without. So, all other things being equal, the rate of mental illness in a country should correlate with the suicide rate. Of course, all other things are not equal, and other factors might come into play such as the quality of mental health services. But it still seems as though there should be a correlation, albeit not a perfect one, between mental illness and suicide.
I decided to see whether or not there is such a correlation. The World Health Organization (WHO) provides the relevant data here. There have only ever been three studies attempting to measure rates of common mental illnesses internationally (1,2,3), and all three were run by the WHO. The WHO also collates national suicide rates (here) for most countries, although a few are missing. No-one seems to have published anything looking for a correlation between these two sets of numbers of before, or if they did, I've failed to find it.
So what's the story? Take a look -
In short, there's no correlation. The Pearson correlation (unweighted)r = 0.102, which is extremely low. As you can see, both mental illness and suicide rates vary greatly around the world, butthere's no relationship. Japan has the second highest suicide rate, but one of the lowest rates of mental illnesses. The USA has the highest rate of mental illness, but a fairly low suicide rate. Brazil has the second highest level of mental illness but the second lowest occurrence of suicide.
*
Some technical notes: Two of the three surveys, the ICPE (2000) and the WMHS (2004), sampled the whole population of each country. The other one, which was also the earliest, the PPGHC (1993), surveyed people attending family doctors. Because this is a slightly different approach, I used the ICPE and the WMHS for the plot above, although the results from the PPGHC are very similar (see below).
The ICPE sampled 7 countries and the WMHS sampled 14, but 4 countries were included in both surveys, so there's a total of 17 countries. I've used the mean of the ICPE and the WMHS for those 4 countries where we have data from both, for the rest I've used whichever is available. For the suicide rates, the WHO gives data for various different years, so I've used 2002, or the nearest available year, since this is between 2000 and 2004. For two countries, Lebanon and Nigeria, the WHO do not report suicide rates. For China, rates of mental illness are given in both Beijing and Shanghai.
The studies used structured diagnostic interviews to try to measure the percentage of people suffering from mental illness in the 12 months before the interview. As I've said previously, this -
attempts to study a random sample of the population of a certain country. In order to establish whether each person is mentally ill or not, they use structured diagnostic interviews. These consists in asking the subject a fixed ("structured") series of questions, and declaring them to have a certain mental disorder if they answer "Yes" to a given number of them.
In this case the structured question interview was called the CIDI and it used DSM-IV criteria. You can check it out here. Example question:
You mentioned having periods that lasted several days or longer when you felt sad, empty, or depressed most of the day. During episodes of this sort, did you ever feel discouraged about how things were going in your life? (YES, NO, DON’T KNOW, REFUSED)
*
The rates from the population surveys (ICPE & WMHS) don't correlate with suicide but they do correlate with the rates from the PPGHC survey of people attending family doctors. The association here is very strong, with a correlation r = 0.693. The only outlier is the US. This is despite the fact that a decade elapsed between the first survey (1993) and the other two (2000, 2004).
This is important because it shows that the mental illness surveys are measuring something about these countries, something which is stable over time. They're not just producing random junk results. But whatever they're measuring, it's not related to suicide.
*
What does this mean? You leave a comment and tell me. But here's my take. I've often expressed skepticism of population surveys and their (very high) estimates of mental illness, and of the dubious political conclusions certain people have tried to draw from them, but even so, I was surprised to find no correlation at all with suicide. I'd say that any meaningful measure of mental illness should correlate with suicide. These surveys, using the CIDI, don't, so to me they're not meaningful.
One thing to bear in mind about these numbers is that they deal with "common" mental illnesses like depression, substance abuse and anxiety. They leave out the most severe disorders such as schizophrenia. Also, people in psychiatric hospitals, in prison, and the homeless, will not have been included in the studies because they sample "households". That could be why there's no association with suicide, but if so then these surveys are missing a very important aspect of mental health. The surveys do seem to measure something, but I don't think it has much to do with mental illness. This is just a guess but I suspect they're measuring willingness to talk about your emotional life to strangers. At least stereotypically, the Chinese and the Japanese are known as more reserved in this regard than Brazilians and Americans. So it's no surprise that when you ask people a load of personal questions, the "rates of mental illness" seem to be lower in Japan than in America. This doesn't mean Americans are really more ill, just more open.
I've been talking about surveys looking at differences between countries, but if these are flawed, then so are surveys looking at just one country. For example, many studies have looked at mental illness in the USA using similar methods to these. But can we trust these methods bearing in mind that if you ask the same questions in, say, Belgium you get less than half the estimated rate despite it having double the number of suicides? Taken to its logical conclusion, maybe we know little about the prevalence of "common mental illness" anywhere. Sartorius N, Ustün TB, Costa e Silva JA, Goldberg D, Lecrubier Y, Ormel J, Von Korff M, & Wittchen HU (1993). An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on 'Psychological Problems in General Health Care'. Archives of general psychiatry, 50 (10), 819-24 PMID: 8215805
WHO (2000). Cross-national comparisons of the prevalences and correlates of mental disorders. WHO International Consortium in Psychiatric Epidemiology. Bulletin of the World Health Organization, 78 (4), 413-26 PMID: 10885160
Demyttenaere K, & et Al (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA, 291 (21), 2581-90 PMID: 15173149
VENHA PRA CÁ E LEIA COMIGO ESTE CONTO. É EMOCIANTE.A FORÇA DO AMOR MOVE TUDO.TE ESPERO LÁ COM O SEU COMENTARIO E PARTICIAÇÃO.BLOG UMA INTERAÇÃO DE AMIGOS TE ESPERA.DESDE JÁ, AGRADEÇO O IMENSO CARINHO E RESPEITO, QUE VOCÊ ME DEDICA.AMO CADA UM QUE PASA POR AQUI.
The authors are Devinsky, Sacks, and Devinsky - Sacks being neurologist and author Dr. Oliver Sacks. Their anonymous patient, a 51 year old married American man, is currently serving a jail sentence for downloading child pornography. But he's not your average pedophile.
The man's problems began at the age of 19 when he -
first suffered attacks of déjà vu ... They became much more frequent – as many as 20 attacks a day – and much more complex, the déjà vu now being followed by a cascade of other symptoms: sharp pains in the chest and sensations of breathlessness; alterations of hearing; occasional musical hallucinations – he would always hear a particular song ‘as clearly as if it were being played in the next room’...
Tests showed that these strange sensations were the result of epilepsy, and that the seizures originated in the right mesial temporal lobe, an area of the brain involved in memory and emotion. Temporal lobe epilepsy is relatively common, and it's a fascinating topic in itself, as the symptoms often include hallucinations and other odd experiences such as a powerful sense of déjà vu.
As time went on the symptoms worsened, and anticonvulsant drugs didn't help, so at age 33, the patient had surgery to remove the part of the brain where the seizures were starting. Tests on the brain tissue removed in the operation showed the presence of a brain tumour (ganglioglioma). However, a few months later, the seizures returned, worse than before. So, at age 39, he had a second operation to take out even more of his right temporal lobe. That's when his real trouble started -
Approximately a month after surgery, behavioral changes of irritability, hyperphagia [increased eating] and hypersexuality (including coprophilia) developed. He became more sexually active with his wife and masturbated more often. Compulsively, he began to watch adult pornographic images and videos on the internet when his wife slept.
The unfortunate patient's symptoms are a rare example of Klüver-Bucy Syndrome (KBS) in man. Here's the very first account of it -
He no longer clearly understands the meaning of the sounds, sights, and other impressions that reach him. His food is devoured greedily, the head being dipped into the dish, instead of the food being conveyed to the mouth by the hands. He reacts to all kinds of noises, even slight ones – such as the rustling of a piece of paper – but shows no consequent evidence of alarm or agitation and displays tyrannizing proclivities towards his mate.
That's a description of a lab monkey, written in 1888 by British neuroscientists Sanger Brown and E. A. Schaefer. Compare it to the patient's own words about what happened to him -
My appetite for food and sex increased dramatically. I had greater mood swings. I wanted sex constantly. Every day. I was very easily stimulated and began to touch myself regularly. I began to request sex daily from my wife. If I wasn’t having sex with my wife, I masturbated. This behavior increased over time. I became more emotionally labile, obsessive–compulsive... I become distracted so easily that I can’t get anything started or done.
It's a classic example of KBS, although the patient only had his right temporal lobe damaged, whereas in monkeys KBS usually follows removal of both the left and the right temporal lobes. Also, it's interesting that the symptoms only started a month after the surgery.
The patient's appetite for sex (and food) was insatiable, and this became his downfall -
Some websites solicited him to view and purchase child pornography. He became obsessed with this and eventually purchased and downloaded pornographic images of prepubescent females engaged in sexual activities from the internet. He was ashamed and secretive about these activities, not discussing the pornography or masturbation with his wife or with anyone else.
In 2006, he was arrested. A psychiatrist prescribed an antipsychotic, quetiapine, and an antidepressant, sertraline. His sexual obsessions disappeared, and according to his wife, "he became much warmer and loving but the medications shut off his libido... sex became non-existent."
The patient was subsequently charged with 'knowingly and wilfully possessing material which contained at least three images of child pornography'. He plead guilty. Dr Devinsky told the court that the right temporal lobe damage was the "major contributing factor to the patient’s hypersexuality and viewing of child pornography" and that he was, therefore, not responsible for his actions. Oliver Sacks agreed, saying a letter that he was
. . . a man of superior intelligence and of real moral delicacy and sensibility, who at one point was driven to act out of character under the spur of an irresistible physiological compulsion resulting from his brain injury. A recurrence of such behavior is extremely unlikely given his character and insight... He is strictly monogamous.
The prosecution, however, argued that he was in control of actions, because he was able to avoid acting inappropriately in public, and they sought the maximum sentence possible - 20 years. They said that
the patient’s hypersexual behavior in some situations but not others was evidence for volitionally controlled criminal behavior; that it was incompatible with a neurological cause. For example, he downloaded and viewed child pornography at home but not at work.
The judge, however, accepted that the patient's medical condition was a mitigating factor in the case. He sentenced him to 26 months imprisonment, 25 months home confinement, and 5 years under supervision - the minimum punishment allowable by law.
Should he have been punished at all? Devinsky, Sacks, and Devinsky don't think so: "Was he criminally responsible? Did his behavioral actions warrant imprisonment? We believe the answer is no to both questions."
But the case raises difficult questions about free will and responsibility. At first glance, it seems as though the man's brain damage didn't directly make him download the child porn, but merely gave him an "urge" to do so. Don't we have the ability to choose whether or not to follow our urges? Isn't that what "free will" is?
On the other hand, damage to the same parts of the brain causes strikingly similar symptoms in monkeys. An alien scientist observing life on earth might well conclude, from cases like this, that all the species of monkeys on this planet are very similar - including humans. You damage a certain part of their brains, and their behaviour changes in a predictable way. Most of us humans would say that other monkeys don't have "free will" - but then how are we so sure that we do?
Devinsky J, Sacks O, & Devinsky O (2009). Kluver-Bucy syndrome, hypersexuality, and the law. Neurocase : case studies in neuropsychology, neuropsychiatry, and behavioural neurology, 1-6 PMID: 19927260
The authors are Devinsky, Sacks, and Devinsky - Sacks being neurologist and author Dr. Oliver Sacks. Their anonymous patient, a 51 year old married American man, is currently serving a jail sentence for downloading child pornography. But he's not your average pedophile.
The man's problems began at the age of 19 when he -
first suffered attacks of déjà vu ... They became much more frequent – as many as 20 attacks a day – and much more complex, the déjà vu now being followed by a cascade of other symptoms: sharp pains in the chest and sensations of breathlessness; alterations of hearing; occasional musical hallucinations – he would always hear a particular song ‘as clearly as if it were being played in the next room’...
Tests showed that these strange sensations were the result of epilepsy, and that the seizures originated in the right mesial temporal lobe, an area of the brain involved in memory and emotion. Temporal lobe epilepsy is relatively common, and it's a fascinating topic in itself, as the symptoms often include hallucinations and other odd experiences such as a powerful sense of déjà vu.
As time went on the symptoms worsened, and anticonvulsant drugs didn't help, so at age 33, the patient had surgery to remove the part of the brain where the seizures were starting. Tests on the brain tissue removed in the operation showed the presence of a brain tumour (ganglioglioma). However, a few months later, the seizures returned, worse than before. So, at age 39, he had a second operation to take out even more of his right temporal lobe. That's when his real trouble started -
Approximately a month after surgery, behavioral changes of irritability, hyperphagia [increased eating] and hypersexuality (including coprophilia) developed. He became more sexually active with his wife and masturbated more often. Compulsively, he began to watch adult pornographic images and videos on the internet when his wife slept.
The unfortunate patient's symptoms are a rare example of Klüver-Bucy Syndrome (KBS) in man. Here's the very first account of it -
He no longer clearly understands the meaning of the sounds, sights, and other impressions that reach him. His food is devoured greedily, the head being dipped into the dish, instead of the food being conveyed to the mouth by the hands. He reacts to all kinds of noises, even slight ones – such as the rustling of a piece of paper – but shows no consequent evidence of alarm or agitation and displays tyrannizing proclivities towards his mate.
That's a description of a lab monkey, written in 1888 by British neuroscientists Sanger Brown and E. A. Schaefer. Compare it to the patient's own words about what happened to him -
My appetite for food and sex increased dramatically. I had greater mood swings. I wanted sex constantly. Every day. I was very easily stimulated and began to touch myself regularly. I began to request sex daily from my wife. If I wasn’t having sex with my wife, I masturbated. This behavior increased over time. I became more emotionally labile, obsessive–compulsive... I become distracted so easily that I can’t get anything started or done.
It's a classic example of KBS, although the patient only had his right temporal lobe damaged, whereas in monkeys KBS usually follows removal of both the left and the right temporal lobes. Also, it's interesting that the symptoms only started a month after the surgery.
The patient's appetite for sex (and food) was insatiable, and this became his downfall -
Some websites solicited him to view and purchase child pornography. He became obsessed with this and eventually purchased and downloaded pornographic images of prepubescent females engaged in sexual activities from the internet. He was ashamed and secretive about these activities, not discussing the pornography or masturbation with his wife or with anyone else.
In 2006, he was arrested. A psychiatrist prescribed an antipsychotic, quetiapine, and an antidepressant, sertraline. His sexual obsessions disappeared, and according to his wife, "he became much warmer and loving but the medications shut off his libido... sex became non-existent."
The patient was subsequently charged with 'knowingly and wilfully possessing material which contained at least three images of child pornography'. He plead guilty. Dr Devinsky told the court that the right temporal lobe damage was the "major contributing factor to the patient’s hypersexuality and viewing of child pornography" and that he was, therefore, not responsible for his actions. Oliver Sacks agreed, saying a letter that he was
. . . a man of superior intelligence and of real moral delicacy and sensibility, who at one point was driven to act out of character under the spur of an irresistible physiological compulsion resulting from his brain injury. A recurrence of such behavior is extremely unlikely given his character and insight... He is strictly monogamous.
The prosecution, however, argued that he was in control of actions, because he was able to avoid acting inappropriately in public, and they sought the maximum sentence possible - 20 years. They said that
the patient’s hypersexual behavior in some situations but not others was evidence for volitionally controlled criminal behavior; that it was incompatible with a neurological cause. For example, he downloaded and viewed child pornography at home but not at work.
The judge, however, accepted that the patient's medical condition was a mitigating factor in the case. He sentenced him to 26 months imprisonment, 25 months home confinement, and 5 years under supervision - the minimum punishment allowable by law.
Should he have been punished at all? Devinsky, Sacks, and Devinsky don't think so: "Was he criminally responsible? Did his behavioral actions warrant imprisonment? We believe the answer is no to both questions."
But the case raises difficult questions about free will and responsibility. At first glance, it seems as though the man's brain damage didn't directly make him download the child porn, but merely gave him an "urge" to do so. Don't we have the ability to choose whether or not to follow our urges? Isn't that what "free will" is?
On the other hand, damage to the same parts of the brain causes strikingly similar symptoms in monkeys. An alien scientist observing life on earth might well conclude, from cases like this, that all the species of monkeys on this planet are very similar - including humans. You damage a certain part of their brains, and their behaviour changes in a predictable way. Most of us humans would say that other monkeys don't have "free will" - but then how are we so sure that we do?
Devinsky J, Sacks O, & Devinsky O (2009). Kluver-Bucy syndrome, hypersexuality, and the law. Neurocase : case studies in neuropsychology, neuropsychiatry, and behavioural neurology, 1-6 PMID: 19927260
QUERO AGRADECER A COMPANHIA MARAVILHOSA DE TODOS. HOJE CEDO, FUI RETIRAR OS PONTOS DO MEU PÉ. MAIS, AINDA FICAREI MAIS 30 DIAS SEM PISAR, OU MAIS...DEPENDE DO MÉDICO..
OS PONTOS SÃO NO LADO DE FORA DO PÉ. TEM UMA PLANTINA E QUATRO PARAFUSOS.
