Suicidologia în România – tradiţii şi perspective

I. Worldwide studies of suicidology

The first authors concerned with the suicide problem were the famous French authors of the 19th century: Esquirol, Achille-Delmas and Deshaies.

The French Psychiatric School, mainly Esquirol, describe suicide from the “alienist’s” point of view, thinking that those comitting this act suffer from a mental illness. But the most important study of the 19th century is, undoubtedly, that of sociologist Emile Durkheim: „Le suicide. Étude sociologique”, published in Paris, in 1897⁽¹⁾.

Related to the study of social factors, Durkheim classifies the autolytic behaviour into three distinct categories:

• Egocentric suicide

• Altruistic suicide

• Anomic suicide

In the early 20th century, Freud⁽²⁾ published two essential studies for the understanding of suicide as a mental illness. The first one is Mourning and melancholia (1917) and the other is The Ego and the Id (1923). Freud develops not only the concept of aggression returned towards Ego but also the concept of Thanatos, specific to the instinct of death.

After World War II, suicidology appeared as an independent subject. Edwin Shneidman was the most prominent personality in this field, professor of Thanatology and Suicidology at the California University. He opened, in 1958, the first centre for suicide prevention in USA – Los Angeles Suicide Prevention Centre.

Shneidman⁽³⁾ (1993) assumed that suicide was the consequence of an overwhelming psychic disorder named psychache. The central factor in suicide would be the apparition and persistance of psychache, secondary to the frustration of vital needs. The importance of other risk factors is well known, but the most significant element for understanding and anticipating suicide is the impact of these factors on experiencing psychache.

Since the 70’s, A. Beck⁽⁴⁾ dealt with aspects related to suicidal behavior from the point of view of cognitive theory and he composed several evaluation scales for suicide (The Scale of Suicidal Intention, The Scale of Despair etc.). Beck states that despair would be the central factor of suicide because despair penetrates every component of cognitive triad: belief about yourself, about the relationship with the others and about future.

II. The history of suicidology in Romania

1. The pre-war and interwar period

The suicide problem was scientifically analyzed mainly by the experts in forensic medicine, people who had to accurately identify the causes of a person’s death.

Among the medical experts who approached the suicide problem in their works there were prof. dr. Mina Minovici, the manager of Forensic Medicine Institute in Bucharest, prof. dr. Nicolae Minovici, dr. Marius Constantinescu, dr. Theodor Vasiliu, forensic chemist N. Ioanid.

At the end of the third decade of the 20th  century, Dr. Mina Minovici⁽⁵⁾ published Tratat complet de medicină legală (A comprehensive treaty of forensic medicine), in two volumes, as a climax of his entire experience in the field. In volume II of the above mentioned treaty, the problem of suicide is extensively analyzed in Chapter IV, The etiological diagnosis of the medical fact. Dr. Mina Minovici approached aspects such as the etiology of suicide (causes, age, sex, civil status, occupation, nationality) and types of suicide, based on the statistical data provided by the Forensic Medicine Institute between 1895 and 1916.

Some interesting approaches concerning suicide and the role of forensic doctors in identifying the suicidal acts were published in the first editions of Forensic Medicine Magazine (Revista de Medicină Legală) in 1936, the debut year of this publication.

Thus, in the article “Moral contagion in suicide and the press”, dr. T. Vasiliu⁽⁶⁾ and dr. Marius Constantinescu⁽⁷⁾ raised awareness that press contributed to the spread of information about suicide with carbon oxide, an aspect reflecting what they had named “suicidal epidemic”.

2. Suicidology in Romanian communist period

During the communist regime, suicide problem preoccupied both forensics or profilers and the psychiatrists. Despite the fact that suicides were recorded as a death cause, between 1945 and 1989 this subject was tabu for the communist regime, alongside mental illness, institutionalized children or the existence of AIDS.

That is why there was no systematized research program for the suicide problem that was approached only from a statistic perspective by the Forensic Medicine Institute or as an auxiliary product of mental illness: The current situation of mental illnesses. The program for promoting and protecting population mental health during 1972‑1980.

Furthermore, suicide as a psychopathological fact was marginally approached in psychiatric studies or monographies, such as that published in 1981 by Petre Brânzei and Aurelia Sârbu⁽⁸⁾ (Psychiatry, Bucharest, 1981) or in Epidemiological psychiatry in 1983, published by de V. Angheluţă, Ştefan Nica-Udangiu and Lidia Nica-Udangiu⁽⁹⁾.

A major contribution was that of prof. dr. Gheorghe Scripcaru⁽¹⁰⁾, from Iaşi, preoccupied by forensic psychiatry (Forensic pathology. Forensic thanatology). V. Predescu, Ştefan Nica-Udangiu and Lidia Nica-Udangiu⁽¹¹⁾ were preoccupied by emergency in psychiatry and the necessity for an emergency intervention in people who had a suicidal behaviour. Thus, in the study Emergencies in psychiatry, published in 1983, the three authors included among the main groups of psychiatric emergencies the patients with suicide attempts or self-aggressive behavior.

New studies analyze suicide in some problematic age groups such as the study dedicated to suicide in juvenile people written by M. Burdea, A. Todoranu and Z. Burduja⁽¹²⁾: Suicide in children and teenagers, published in Medical Life in 1968.

Another volume in the same period – Mental health in contemporary world, published in 1986, coordinated by V. Mironţov-Ţuculescu, V. Predescu and C. Oancea⁽¹³⁾ – approaches the problem of suicide in chapter III, “Suicidal conduct. Frequency, causes, influencing methods”, edited by Ştefan Nica-Udangiu and A. Nicolau.

III. Suicidology in post-communist period

After the Revolution, research in the field of suicidology could be manifested freely, connected to the similar initiatives in the western countries. Approaches are diverse, escaping the sphere of clinical psychiatry or forensic medicine, entering the field of other sciences such as psychology, sociology, bioethics, history, theology, etc. If we list some reference titles, we have to mention: Vladimir Beliş⁽¹⁴⁾, Treaty of forensic medicine, Chapter 2. “General forensic thanatology”; Bogdan V. Delavrancea⁽¹⁵⁾, Autonomy and independence of conscience and its relationship with the suicidal act, or (Do we have two realities in a person, body and soul?); Predescu V., Psychiatry⁽¹⁶⁾; Doina Cozman⁽¹⁷⁾, Suicide. Study in bio-psycho-social perspective; Doina Cozman⁽¹⁸⁾, Suicide in Romania; Florin Ene⁽¹⁹⁾, Psychological autopsy and suicide; Tudorel Butoi, Valentin Iftenie, Alexandru Boroi, Alexandru Butoi⁽²⁰⁾, Suicide, a paradox. Psycho-sociological, bio-medical and legal considerations; M. Birţ⁽²¹⁾, Suicide and aggression in the Bible. Reflection on king Saul’s death etc. A historical perspective of the suicidal phenomenon is offered by the work published in 2005, Underground Bucharest: Suicide, coordinated by Adrian Majuru⁽²²⁾. New doctoral theses were dedicated to this subject hidden in the past, by enlarging the sphere of theoretical knowledge with statistical data: Doina Cozman⁽²³⁾, Suicide. Nosographic classification and therapeutical implications (1995); Veress Albert⁽²⁴⁾, Some epidemiological, clinical and therapeutical-prophylactic aspects of suicide in Harghita county (1997). More and more works were dedicated to the study of the relationship between depression and suicide in different age groups or risk categories. Thus, the book of prof. dr. Roxana Chiriţă⁽²⁵⁾ was published, Depression and suicide: biological and axiological dimensions. Some more recent works about suicide extend research to new directions, promoting interdisciplinarity. We cite the works of Silviu Morar⁽²⁶⁾, The contribution of forensic medicine to the interdisciplinary study of suicide, that approach suicide from the perspective of forensic medicine. Furthermore, Doina Cozman published a monography entitled Compendium of suicidology⁽²⁷⁾, in 2006, as well as a chapter dedicated to  suicide prevention in Romania, within the treaty of suicidology: Oxford Textbook of Suicidology and Suicide Prevention⁽²⁸⁾. In Iaşi, Călin Scripcaru⁽²⁹⁾ published the monography The suicide. A constant concern of suicidologist dr. Veress Albert was getting together in Miercurea‑Ciuc, every two years, people interested in studying and treating the autolytic behavior, during a series of conferences initiated since 2000.

Under the coordination of dr. Veress they also took into account the publication of the works presented at this conferences, out of which we mention the first two volumes: Autolytical conducts. Deviances of personality (2000), respectively Affective disorders. Autolytical behavior, in 2002. An extremely important contribution to the consolidation of suicidology as a science was that of prof.dr. Doina Cozman and the team under her coordination from UMF Cluj-Napoca and represented by associate professor dr. H. Coman, dr. B. Nemeş, dr. D. Herţa, dr. M. Manea, dr. O. Dobrescu, psychologist V. Dumitru, etc. This team of experts in suicidology carried out research programs at national and international level. Through European projects SEYLE and WE-STAY (financed by the European Commission – program FP7) where the group of Cluj researchers took part, scientifical data for an evidence-based medicine were provided. These European projects WE-STAY and SEYLE, carried out between 2007 and 2013 in 11 European countries, including Romania, support the conclusion that in teenagers the risk behaviors are present to a greater extent than it was appreciated before the researches. Among the original works of the above mentioned researchers, published in extenso, we mention two articles published in the prestigious international magazines that benefit from hundreds of citations: Wasserman et al., School-based suicide prevention programs: the SEYLE cluster-randomized, controlled trial (2015); Zalsman et al., Suicide prevention strategies revisited: 10-year systematic review (2016).

IV. The impact of suicidology as a science
in social life

The confirmation of suicidology in Romania was possible inclusively through NGOs dedicated to suicide prevention. Thus, prof. dr. Doina Cozman supported in Cluj, for the first time in Romania, a Crisis Line for suicide cases in students (Cluj Antisuicide Alliance, 1993), and in 2010 she founded together with other 15 experts in mental health the Romanian Alliance for Suicide Prevention (RASP). Last but not least, we have to mention the social impact of the Antisuicide Green Line (0800 801 200), set up by RASP in 2015, with tens of daily phone calls with people during emotional or even suicidal crises.

Foundation “Cry for Help”, in Harghita county, president dr. Veress, has a successful activity. We have to mention that this county has the highest rate of suicide in Romania. A crisis phone line is associated to this foundation and involves volunteers who speak Hungarian during their phone calls. The Suicidology Association in Bucharest, having as president dr. Elena Brănaru, founded emergency phone line Telverde (0800.080.100) for children and teenagers with self-destructive imminent behavior. Furthermore, the association got from ANCOM the number 116.123 assigned by the European Commission as a harmonized number with social character. Also, the association focused on methods of active detection of suicidal risk in children and teenagers through screening tests (ASEBA) validated in Romania for pupils in Bucharest and other counties in Romania. RASP and Cry for Help have coordinated their efforts, since 2015, and organize every year The National Day for Suicide Prevention in different Romanian towns, supporting a better dissemination of suicide prevention methods among physicians of every specialization but also among general population.

A conclusion can be drawn at the end of this brief overview related to the stages of suicidology as an independent science in Romania: over time, the study of suicidology preoccupied mainly the representatives of medicine, both forensic experts or psychiatrists, people who faced directly the consequences of a suicidal act.

We mention that the rate of suicide in Romania has an average value compared to other European countries (approximately 12 suicides in 100,000 inhabitants) but we do not consider these figures encouraging.

Experts’ efforts in the field of mental health have to rely on the evidence provided by researchers. Furthermore, young people have to be targeted because they have additional risks generated by the invasions of drugs, their addiction to internet and social media. European programs centered on teenagers intended to initiate actions of awareness-raising related to risk behaviour and to develop coping specific methods aiming at reducing risky and suicidal behaviors among young people. The effect of these programs were the contouring of some principles for suicide prevention that were not materialized so far within a national strategy, legally applied in every Romanian mental health service.