An Evolutionary Perspective on Depression, Suicide and Tobacco Use

Emerging Fronts in the Global War on Disease

Edward H. Hagen

The global burden of disease is increasingly caused by

“mental illness”

Part I: Depression & suicide

Infectious disease

These work extremely well:

Antibiotics

Mental disease

These don’t:

Antidepressants and talk therapy are not much better than placebo

Any antidepressant: ! 50% improvement in symptoms for 50% of patients

Talk therapy: ! 50% improvement in symptoms for 50% of patients

Placebo: ! 30% improvement in symptoms for 50% of patients

Williams et al. 2000 Meta-analysis

Might be no clinically significant effect when unpublished studies are included.

Kirsch et al 2008

Half a century of research on depression: No improvement in treatment

Current NIH funding level for depression research:

$402 million / year

First & second generation antidepressants (1950’s)

Current generation antidepressants

Global burden of disease (DALYs): The top 10

High income countries: Problems that even money can’t solve

Global burden of disease (DALYs): The top 10 Low and middle income countries

Depression is a major risk factor for suicide

Worldwide, suicide causes about the same number of deaths as all wars and homicides combined (WHO 2002).

A new paradigm might be needed

My simple idea

To solve a major life problem

Change yourself Change others

Suicidality as a strategy to change others when those others don’t want to change

The basic idea

If others won’t change…

Threaten to hurt others Threaten to hurt themselves

The strong The weak

The weak are still extremely valuable

As

•!Offspring •!Siblings •!Mates •!Friends

How to hurt others by hurting oneself

!t x

A

1-xA

t

Two players, A & B, make alternating offers, x, each round

xB

1-xB

Joint value of cooperation between A & B

Suicide attempt

Complete information No suicide attempts

Value of pie to B is known by A, and visa versa

Complete information No suicide attempts

!A = !

B

This offer accepted immediately by B, even though there are conflicts of interest

Incomplete (private) information: Suicide attempts

Valuations are private

Incomplete (private) information: Suicide attempts

Shrinking pie pressures each party to reach a deal quickly.

Series of offers and counter-offers gradually reveals private valuations of both parties, albeit at the cost of a smaller pie to divide (suicide attempts).

Once private information is revealed, game reduces to one with complete information.

If the suicide attempt succeeds, the strategy fails!!!!

The ethnographic record

In conflicts, is suicidality a strategy of the weak to threaten or hurt the

strong?

Suicidality in cross-cultural perspective

•! Human Area Relations Files (HRAF)

•! 800,000+ pages on all aspects of cultural and social life.

•! 365 different cultural, ethnic, religious, and national groups.

•! Full text materials indexed at the paragraph level and electronically searchable.

Cross-cultural sample

•! All paragraphs in electronic HRAF coded for ‘suicide’ (code = 762)

•! 484 paragraphs from 312 documents of 97 cultures.

•! Content ranges from brief mention of suicide to detailed case studies or analyses of suicide.

•! Two types of relevant material:

–! Author’s observations or assessment of suicidality in a particular culture (does suicidality have a social function?).

–! 323 cases of suicidal behavior (does suicidality yield benefits?).

Geographical distribution of 97 cultures

Social complexity ! Low (village level political organization only) ! High (supra-village level political organization)

Temporal distribution of suicide accounts

Suicide in the ethnographic record

Trobriands

Malinowski: [Suicide] is performed as an act of justice, not upon oneself, but upon some person of near kindred who has caused offence. As such it is one of the most important legal institutions among these natives.

[S]uicide, or the possibility of suicide, serves as a sanction in situations of controversy or dispute.

Fishing/agriculture

Truk Island Group, Micronesia Anger suicide as Amwunumwun

Hezel (1984): The refusal of a boy to eat when his parents have offended him is an example of amwunumwun…. Amwunumwun, therefore, is a strategy of withdrawal or self-abasement used to show those one must both love and obey that one is hurt by them. The act of amwunumwun is intended not principally to inflict revenge—although it would be naive to maintain that there is nothing of this in the act—but to dramatize one's anger, frustration and sorrow in the hope that the present unhappy situation will soon be remedied. If the one who employs amwunumwun is trying to shame the one who has offended him it is always with the intention of showing the offending party the sad state into which their relationship has fallen so that he will take steps to restore it to what it once was or should have been…. [Suicide] is the extreme form of amwunumwun since it means inflicting the ultimate harm upon oneself in order to compel the parents or others to recognize the harm they have done and to repair it. This type of suicide can be, paradoxically, a gesture of both despair and hope at one and the same time.

Truk Island Group, Micronesia

“The suicide act is usually explained by Trukese themselves as motivated by anger, particularly towards those to whom negative feelings should not be shown….” (Hezel 1984)

Anger (120)

Shame/Fear (19)

Psychotic (10)

Suicide in the ethnographic record

Metaco, Gran Chaco

Metraux (1943): There is no doubt

that suicide among these people has a decidedly aggressive

character. The Matako use suicide as a threat; by killing themselves,

they punish the person who has

offended them….

Hunting-gathering/Pastoralism

Suicide in the ethnographic record

Jivaroan Aguaruna, Peru

Brown (1986): Some segments of Aguaruna society — specifically, women and young men who are unable to organize collective responses to conflict — use solitary acts of violence directed against the self to express anger and grief, as well as to punish social antagonists.

Hunting/Horticulture

Suicide in the ethnographic record

Kaska, N. America

Honigmann (1963): A

mechanism involving a threat of

suicide dramatically announced

operates to apply social

pressure. Hunter-gatherers

Suicide in the ethnographic record

Kuma, New Guinea (Highland)

Reay (1959): Suicide attempts are “expected” of women when they are contractually married. The suicide attempt is always by drowning. The attempt only occasionally results in the death of the individual. The suicide attempt is an accepted method of protest against the relatives who have brought about the undesired match....

Agriculture

Suicide in the ethnographic record

Gilbert Islands

Wilkes (1845): The motive of [suicide] is generally the treatment they have received, or offence taken at the conduct of some person, whom affection or fear renders them unwilling to injure; the mortification and grief produced thereby leads them at last to suicide, which is considered by them as a remedy for their evils, as well as a severe revenge upon those who had ill-treated them.

Fishing/Horticulture

Suicide in the ethnographic record

Ovimbundu, Angola

Edwards (1962): Suicide

threats are used to put

pressure on others in

disputes.

State-level agriculture

Suicide in the ethnographic record

Fulani, West Africa

Hopen (1958): The suicidal

threat is recognized as an

important form of social

sanction.

Nomadic pastoralism/Trade

Suicide in the ethnographic record

Africa

Jeffreys (1952): In many

cases, suicide functions as

a form of social sanction

against those towards

whom the individual has a

grievance….

Suicide in the ethnographic record

Lepchas

Southern Himalaya

Gorer (1938): An individual who believes himself wronged may attempt to commit suicide; this serves both to affirm his own innocence in the matter in question, and as a public indictment of the transgressor. The individual attempts suicide, but the attempt is made in such situations that he is bound to be saved.

Hunting/Horticulture

Iroquois Region Suicides 1635-1939

Types Retaliation (43%)

Avoid torture (20%)

Committed crime (16%)

Grief (9%)

Illness/decrepitude (5%)

Drunk? (5%)

Shame (2%)

14 female

7 male

Iroquois Region Suicides Retaliation cases (43%)

Examples

•! Wife taken away. •! Fiancé left for another. •! Abandoned by husband. •! Wife was having an affair. •! Wife was verbally abusive. •! Not supported by husband. •! Marital dispute, jealousy. •! Discontent with parental discipline. •! To avoid marriage to undesirable man.

Does suicidality yield benefits?

Most anthropologists focus on completed suicides, so let’s turn to the ethnographic case data on threats and attempts…

Cases Do threats and attempts yield benefits?

•! 17 of 81 threat/attempt cases (21%)

mention a benefit.

•! 35 of 81 threat/attempt cases provide any

information about outcome (17/35 = 49%).

•! These 17 cases are in 12 cultures (7 in

probability sample, and 5 not)

Cultures where threats/attempts yielded a benefit

Example benefits from suicide attempts

Delaware: Cause: Wife was verbally abusive.

Consequence: Emetic forced down throat. Wife "behaved better ever after.”

Korea: Cause: Mother abused 22 year-old son. Consequence: Villagers prevail on mother to be more considerate of her children.

Korea:

Cause: Husband's concubine. Consequence: Concubine is moved out.

Azande: Cause: Man ashamed at violating sex taboo.

Consequence: Friends find man and bring him home "in honour"; esteem they showed him "wiped out the disgrace."

Ovimbundu: Cause: Woman afraid of sorcery, threat to get money.

Consequence: Got money.

Lepcha:

Cause: Young wife hated arranged marriage (loved husband's younger brother) and beaten for cheating on husband.

Consequence: Allowed to marry who she wanted.

Conclusion of part I

1. Cross-culturally, suicide is used by the weak to hurt the strong.

2. Failed suicide attempts often elicit valuable benefits.