Writing on One’s Own Demise: Suicide Notes in the Age of the Internet

One to two people out of six who attempt suicide will leave a note behind. In comparison to notes written on paper, internet suicide notes may differ in a variety of characteristics, as they illustrate different degrees of real-time experiences. Given continuous internet traffic, awareness, likelihood of rapid detection and discovery by potential readers is more likely online. Therefore, internet traffic may change the communication dynamic of suicidal wish and intent. The question posed then is: are internet suicide note writers a different population of suicidal individuals compared to those who leave behind paper suicide notes? While some strides on suicide prevention on the internet are emerging, we propose that four areas of exploration on cybersuicide could benefit from the development of safeguards and intervention: exploration of suicide sites; Facebook traffic on suicide; Suicide blogs and bloggers, and personal Review Article communication via email and social media. While many unanswered questions remain regarding the feasibility of a unified approach, in the long run the development of intervention strategies should become a priority in research. Such strategies would include the development of extended online professional networks. While these networks would create a major privacy challenge for the online community, they may also become a model for addressing healthcare issues online. In order to accomplish such an online community, allocation of significant resources, the development of specialized technology and the worldwide cooperation of mental health professionals would be necessary.


Suicidal Narratives
Suicidal thoughts are common under many circumstances. While these thoughts can be temporary, those who choose to write notes are communicating their intent to die. In J. W. Goethe's novel The Sorrows of Young Werther, the protagonist writes a suicide note and subsequently shoots himself [1]. Werther, a novel of the 1700's, was the first international bestseller and resulted in a copycat epidemic of suicides in Europe. In re-examining Werther today it becomes obvious that suicides that become public stories depict a "suicide narrative"--the entire Werther novel is an epistolary novel written in form of letters. Such suicide narratives can be adopted by an attempter. The suicide note may serve as a rehashing and finalizing script of the suicide narrative that ends in the act of suicide. Current research has proposed that personal narratives are fragments of memory that are owned and organized in the form of a coherent story [2]. For an individual who commits suicide, a note is the end of a gradually built-up personal story: the suicide narrative. Such narrative may be an elaborate history that assesses life (in a cognitive-biased manner) as a long list of failures and disappointments. The self-destructive narrative (often) colored by the presence of a mental illness constitutes the predisposition element of the stress diathesis suicide model [3].

Suicide
is a significant public health issue. Approximately 1 million people commit suicide world-wide every year. Around 10 million attempt suicide each year [4]. In the United States, suicide is the 10th leading cause of death with more than 40,000 suicide deaths per year [5].
Of those who commit suicide, only 15-40% leave a suicide note [6]. Data is limited on the statistics of individuals who commit suicide and leave a suicide note.
Despite evidence suggesting a constant incidence of suicide notes from 1981 to 2001, it has been suggested that incidence of suicide notes might be on the rise over the past decade particularly on the internet and through social media [7].
The advent of the internet and in particular, social media have created a new form of communication and dissemination of information that is instantaneous and anonymous. Users can instantly share and view information such as comments, images, videos via various social media platforms including social networking services (facebook, twitter, instagram), video sites (youtube), blogging (blogspot), chat rooms (chatroulette), and forums. The unregulated content nature of the internet unfortunately poses inherent risks leading to prosuicide behaviors. Cyberbullying via social media and messaging / chat room, online suicide pacts, websites / forums with instructions on how to commit suicide, media contagion effect are vehicles for increased risk of suicidality. Additionally, the ability to instantaneously leave messages, posts, videos, images to the public provides a vehicle for suicide notes, which may in turn influence prosuicide behavior to those who encounter them [8].
Although the Internet and social media have opened up a new avenue for increased prosuicidality behavior and risk to the public, it can also provide a valuable resource for assistance and prevention. Luxton, et al. have suggested that "because social media are mostly created and controlled by end users, the opportunity for surveillance and prevention can be extended to all users. They suggest that all social media sites provide an option for users to report "malicious Web sites and activities of other users." Additionally, public health campaigns, education, awareness and promotion of simple access can be communicated to the immense users on social media [8].

Suicidal Notes
In Leenaars et al.'s review of psychiatrist Dr. Karl Menninger's famous studies on suicide note content, the reviewers found that completers tend to be motivated by anger and revenge and are less likely to have escape as a motive. Notes by completers of suicide tended to show selfblame and self-punishment as well as a common theme of hopelessness throughout the note [9]. In The Suicidal Mind, Shneidman describes unmet needs and psychological pain that lead a person to commit suicide. He argues that it was not the unmet needs per se, but the "prominence, the intensity, and singular importance of a particular need that shape[s] personality and influence[s] life course [towards suicide]" [10]. In particular, the psychological pain from loss of succorance (which is defined as needs satisfied by someone or something) can be a strong precipitant for suicide. Shneidman's conclusions were confirmed by Gunn [11] who also found that escape from psychological pain was a strong motivation for suicide attempts but less predictable when it came to the lethality of the attempt.
Suicide notes have been studied within numerous contexts: day of the week (e.g. Monday for males and Sunday and Monday for females), time of the day (more frequent in the evening and late night), seasonal pattern, weather and symbolic ages (such as 40, 65, 70) [12,13]. In a few studies, note writers died by highly lethal methods but had no history of psychiatric illness or recent psychiatric hospitalization [14,15]. Other studies revealed note non-writers to be more likely to suffer from a psychiatric or physical disorder [16]. Consistent with the "Werther" scenario of suicide which included an explanation and instructions about the suicide, some contributions have pointed to the variety of note contents: feeling like a burden on others, rejection, and anger, "apology/shame" (74%), "love for those left behind" (60%), "life too much to bear" (48%), "instructions regarding practical affairs postmortem" (36%), "hopelessness/nothing to live for" (21%) and "advice for those left behind" (21%) [17]. Conversely, in earlier findings from completed suicide examined by the Los Angeles Suicide Prevention Center, notes tended to be brief, factual, devoid of any colorful elaborate content and suggesting a marked constriction of mental horizon prior to the completion of suicide [18]. Such an emotional constriction may reflect, in some cases, a temporary acute numbing that allows for a relatively painless and detached stance during the act of suicide. Finally, patients that present to the Emergency Department with a suicide note are at increased risk of completing suicide at a later date. Young females with nonwidowed marital status, no history of previous suicide attempts, noprevious psychiatric illness and the presence of religious beliefs tend to leave suicide notes.Those who complete suicide and whose method required little to no preparation leave significantly fewer notes. Elderly females left far fewer suicide notes than elderly males, and the letters were shorter [19,20]. Subjects whose jobs were household duties left fewer notes. Elderly subjects, as a group, left fewer notes which were typically shorter and contained specific instructions [21].

STRESS-DIATHESIS MODEL OF SUICIDE
The stress-diathesis model of suicide behavior postulates the colliding of two components: a) the predispositional vulnerability of an individual, such as pervasive feelings of hopelessness, impulsivity, or aggression; b) The stress component, or events that disturb the psychological balance of the individual such as a psychosocial crises and/or the activation of a psychiatric disorders [3]. We propose that a suicide note interposes itself into this stressdiathesis in some individuals but not in others. Some research points to the fact that victims of suicide have had suicidal thoughts for months or years. In applying the stimulus-affect-response model [22] with suicidal behavior, suicidality may have a progressive course amounting to a critical mass that unleashes the final act of selfdestruction. In such cases the suicide note may constitute an act of explanation and selfjustification [17].
Prior to harming oneself, there may be a period of intense preparation, often associated with trying the means without harming oneself [e.g. putting the gun to head without ammunition), possibly enacting a ritual of decreasing anxiety. The rate of alcohol consumption and cannabis use is higher in people with premeditated suicide, compared with people with impulsive suicidal attempts [23]. Data collected from an online suicidal behaviors questionnaire with a sample size of 48,569 showed that 60% reported past history of suicidal thoughts and 6.8% of the sample group had past history of suicide attempt. Out of those attempters 13.8% had a defined plan. Of these, 60% were impulsive attempts and 22.2% of the suicide attempters had both impulsive and planned attempts [24]. Naturally, people who have planned attempts can also have impulsive attempts and vice versa. Suicide notes of the suicide completers who had a history of previous attempts were less likely to contain themes of apology and shame (58% vs 87%) in comparison to previous non-attempters [17].
Suicide is associated with intent. However, suicidality is known to be fluctuating. In previous studies patients who were rescued in the progress of an attempt did report a subsidence of the suicidal intent [9,25]. Attempters who survived jumps off the Golden Gate Bridge reported a "change of mind" as they were plunging to their expected death [26]. These findings support the lability of the suicidal state and the presence of a window of opportunity for effective intervention and rescue. In conclusion, while a suicide note has been associated with a higher degree of planning and intent, findings also suggest that the state of mind during which a note is written may be labile and transitory. It is only when the act of suicide is completed prior to discovery of the suicide note that such patients' cases become more lethal.

THE INTERNET
Cybersuicide, which refers to suicide and its ideas on the internet, has been described in different forms: 'webcam' suicide, 'net suicide packs', sites that merely offer advice on how to commit suicide and sites that are essential in providing the means of performing the act [27]. A significant body of research regarding suicide content on the internet along with other media has emerged. In an early study, Baume et al described the devastating effect of cybersuicide, including interactive suicide notes [7]. As expected, the phenomenon of spreading of suicidality and the risk for shared suicide reemerged with the advent of the internet. In a German study [28], the coverage of suicide in youth magazines, including articles, notes and pictures did not translate into a "Werther" or copycat effect. Eisenwort's study suggests that context, mode of reporting and language have a significant role in avoiding media glamorization of suicide among teens. This may be consistent with our hypothesis of a suicide narrative that is developed, often results in a suicide note just prior to an attempt and can conceivably be adopted by others. The internet is a medium with a wide and continuous level of accessibility. We propose that it could be used to build safeguard mechanisms that would recognize key words and alert systems to save lives.
In comparison to notes written on paper, internet suicide notes may differ in a variety of characteristics, as they illustrate different degrees of real-time experiences. Given continuous internet traffic, awareness, likelihood of rapid detection, and discovery by potential readers is more likely online. Therefore, internet traffic may change the communication dynamic of suicidal wish and intent. The question posed then is: are internet suicide note writers a different population of suicidal individuals compared to those who leave behind paper suicide notes? Xu et al. [29] have employed Support Vector Machine, a method that produced fine-grained analysis of sentences based in emotional content, and concluded that it is possible to identify critical ranges of emotions. Baume et al. [30] have advocated the role of mental health nurses in internet suicide prevention. This research implies that specific resources have to be allocated to allow for detection of individuals vulnerable to suicide and to uphold the significance of intervention via internet.

CONCLUSION
In conclusion, while some strides on suicide prevention on the internet are emerging, we propose that four areas of exploration on cybersuicide could benefit from the development of safeguards and intervention: exploration of suicide sites; Facebook traffic on suicide; Suicide blogs and bloggers, and personal communication via email and social media. While many unanswered questions remain regarding the feasibility of a unified approach, in the long run the development of intervention strategies should become a priority in research. Such strategies would include the development of extended online professional networks. While these networks would create a major privacy challenge for the online community, they may also become a model for addressing healthcare issues online. In order to accomplish such an online community, allocation of significant resources, the development of specialized technology and the worldwide cooperation of mental health professionals would be necessary.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.