Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38790.495544.7C (Published 04 May 2006) Cite this as: BMJ 2006;332:1058
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We were pleased that our paper generated a wide variety of comments.
While some contributors raised specific points, others referred to more
general issues relating to issues of definition, explanations and
generalisability.
The definition of “Goth” is contentious, but covers a wide range of
musical tastes, social groupings, and aesthetics. The most relevant
distinction here is between contemporary (usually younger) “Baby, Bat or
sometimes referred to as Mall (US)” Goths vs. “mature, real or Elder
Goths” 1. Our paper, as is clear from the title, refers to younger Goths;
the results may not apply to all Goths.
The range of comments in response to our conclusion, that both
selection and influence mechanisms may be involve, reflect the lack of
evidence on this issue. To highlight this, we drew attention in the press
release following publication to the possibility that engagement with Goth
subculture could have positive rather than negative consequences for some
young people. Our contribution is a first step towards producing an
evidence base to test this, rather than relying on media speculation.
Some contributors have suggested that the association between self-
harm and Goth subculture may be accounted for by other factors. However
this is unlikely, since we adjusted for the strongest and most relevant
correlates of self-harm found in other studies of young people. Others
have suggested that our results were not valid due to the small numbers
involved. We would point out that our paper underwent a formal statistical
review before publication. Further, while the media focused on the 25
young people who unambiguously identified as Goth, nearly 8% of our
representative sample had identified with Goth subculture, in varying
degrees of intensity, and were 3-4 times more likely to self-harm, than
the other participants.
It has also been suggested that by adopting a quantitive approach we
may have missed contextual factors (this is obviously true of any non-
qualitative study), and that the high rate of self-harm found among Goths
is a form of decoration, analogous to body modification. We dispute this
on two grounds. Firstly, since those who self-harmed were asked why, we
know that the majority, regardless of youth subculture did so to relieve
anxiety, anger and other negative emotions. Secondly, while cutting could
be interpreted as some form of subcultural display, such an argument is
difficult to sustain in relation to attempted suicide.
1 Wikipedia contributors, 'Goth', Wikipedia, The Free Encyclopedia,
10 May 2006, 07:57 UTC,
<http://en.wikipedia.org/w/index.php?title=Goth&oldid=52455549>
[accessed 10 May 2006]
Competing interests:
None declared
Competing interests: No competing interests
I have enjoyed reading the paper and all responses. Here, there are
few "statistical" commments. There seemed to be several flaws in the
design and execution of this study.
1. are the results valid?
Authors don't give us clear description of how subjects were
identified and recruited. Did they volunteer? How many refused to
participate in the study? The researchers could simply have sampled the
participants in such a way as to increase the chance of supporting their
hypothesis.
Cohort should be representative of a true population for study to be
valid. Some researches use randomization procedure in cohort studies in
order to choose sample, which is the most accurate picture of population.
2. Follow-up/attrition rate.
Follow-up in this study was probably long enough (8years). However,
in 1994, there were 2586 participants, whereas by the year 2002/04 only
1258. Could those followed-up be a biased sample? Loss of participants may
effect precision and power of the study. For example, in Table 3 under
Model 1 Goth subculture there is wide confidence interval (4,42 to 45,39),
which may point out to undepowered study (type II error).
3. Observer Bias?
Outcomes have been assesed using Voice-DISC. Participants were asked
varies questions on: suicide, self-harm, identification with subculture.
It is not mentioned how raters conducted the interviews, whether they used
structured or semi-structured protocol, whether they were blind to the
study's hypothesis.
The more subjective rating is, the more important blinding becomes. The
bias introduced by non-blinding is likely to overestimate findings.
It seems that a decision of belonging to one subculture or another was
rather subjective (participants' responses were assessed on a five point
scale). All in all, no blinding, lack of structured interview,
subjectivity can lead to observer bias.
4. Confounders
Reseachers did adjust for some confounders (sex, social class, etc)
using logistic regression. However, as somebody has already pointed out,
the list of potential confounding factors is long, inc physical illness,
obesity, family hx.
5. Results
For prospective studies outcomes are best presented as a relative
risk.One can comment then on prevalence or incidence of the disorder. In
this study authors use odds ratio.
6. Study's applicability
Is this study applicable in different subcultures? Probably not. In
Table 3, which shows relationship between self-harm and type of
subculture, majotiry of results are statistically non-significant.
In conclusion,
In cohort studies a group of individuals is followed-up over a period
of time. The individuals should be free of the outcome (here: self-
harm/attempted suicide)at the beginning of follow-up. The cohort is
defined by exposure status(here: Goth subculture), which should be found
out before outcome is known. Cohort study measures whether exposure
effects the incidence/prevalence of the outcome,i.e. whether
identification with Goth subculture increases the risk of self-harm or/and
suicide. Researches believe that yes. By reading and critically analysing
this study, I have arrived at different conclusions.
Competing interests:
None declared
Competing interests: No competing interests
The article (Prevalence of deliberate self harm and attempted suicide
within contemporary Goth youth subculture: longitudinal cohort study: BMJ
332) presents society at large with an interesting challenge. Self harm
has been popularised by the media to exist amongst such youth subcultures
through numerous films and documentaries which has not often been
thoroughly evidence based.
This article despite studying a relatively small cohort of youth in
an environment that is not at all throroughly representative of the
country has qualitatively demonstrated an increased bond between self harm
and attempted suicide to those young people who engage in Goth cultural
practices.
The challenge that such an article presents is that in an era where
individualistic mind sets and world views reign supreme how can society be
reconciled to such people who through such practices are a significant
threat to their own existences and thus society at large?
Surely anyone reading this article would wish to decrease the
incidence of self harm and attempted suicide amongst those so young. To do
so one would have to discourage the number of young people becoming
enveloped in such a culture especially when one considers that the strong
connection to the above two disadvantageous scenarios is not weakened by
removing any cofounding factors.
But can such a quest be executed to any success when personal
liberties reign supreme (e.g. you cannot even smack a child on the
underground these days so although society may show concern about Goth
culture who are you to discourage anyone to be caught by its attraction?)
It would be interesting to compare the rates of self harm and
attempted suicide to other youth subcultures whom society shows concern
toward (e.g. hip-hop youth culture). Further it would be interesting to
ascertain any steps that have been taken (i.e. medical and political)
through the decades to discourage the youth from becoming members of some
of the most supposedly destructive clubs around and how effective they
have been.
Although such research is interesting it should be more than an
academic discipline. What problems does such research hope to solve?
Ultimately how does such research hope to improve society? The reason for
my questions is that it has now been known for many many years although
maybe not conclusively shown that such links exist and nothing apparently
has been done at both a medical and political stage. Thus is this research
just purely academic? If so then it is not worth pursuing!
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor, I'm writing in response to the article in the 6th May
Edition of the BMJ "prevalence of deliberate self harm and attempted
suicide within contemporary goth youth subculture: longitudinal cohort
study"
I fear the conclusions drawn may be misleading to clinicians and to
the mass media.
As Young himself stated to the BBC: Only 2 people identifying
themselves with the goth subculture self-harmed afterwards. He also
suggested that the study needed to be repeated. Can we make
generalisations about a subculture containing many thousands on the basis
of 25 individuals studied?
Young suggests that perhaps identifying with goth was a way of
finding a different outlet for coping and may be protective. I note that,
from my own observation, goth is a permissive subculture where mental
illness, disability ans sexuality may find less discrimination than other
subcultures - perhaps even more so in the image conscious teenage
population.
And how, clinically, does this contribute to improvements in care for
our patients? Can we extrapolate results regarding teenagers to goths in
their 20's 30's and 40's? Can we identify people who used to be goths, or
can clinicians accurately identify people who are goths? Most UK goths
would not consider Marilyn Manson to be goth for example. Can you, as a
clinician, tell the difference between a 'goth' and a 'metaller'? What
about the 90% of teenagers who self harm who aren't goths (73 of 81 people
in this study)?
The truth is that conclusions drawn by this paper are picked up on by
the press, and may well alarm parents and teachers. They may increase
negative associations towards a subculture, thereby increasing rather than
decreasing prejudice already experienced by goths. All this without
necessarily furthering our ability as clinicians to seek out young people
at risk of self harm.
Ref:
BMJ 332, 6 May 2006, 1055-1061
Goths 'More likely to self-harm'
http://news.bbc.co.uk/1/hi/health/4905898.stm
Attacker targets teenage 'goth'.
http://news.bbc.co.uk/1/hi/england/merseyside/4924144.stm
Mick Mercer. 21st Century Goth, 2002, Reynolds & Hearn Ltd.
London. ISBN 1 903111 28 5
Competing interests:
as the study would say, some subcultural identification with "goth"
Competing interests: No competing interests
I shall make no comment on either the quality or significance of this
study, but I would like to point out a result that doesn't seem to have
been discussed. From the data, it would appear that people identifying
themselves as "indie" have an unusually low incidence of self harm. Can we
infer from this that indie music has a protective effect against self
harm? Perhaps indie music should be played to those at risk of self harm?!
One other point I'd like to make is that the friends of people who
self harm are more likely to self harm themselves, as the behaviour can
(in part, at least) be considered a learned coping method. It is also true
that goths tend to be friends with goths. Is it known whether the 15
individuals in this study who identified themselves as "goth" were also
part of the same friend group?
Competing interests:
None declared
Competing interests: No competing interests
It is somewhat unexpected that BMJ would publish such an article,
which attempts to determine traits associated with the Goth subculture—a
grouping which potentially comprises of 100,000s adherents globally—based
on a sample of only 15 individuals in a single locality.
While Goth subculture is the article focus, just two references are
given, and only one of them academic. There is a failure both to consult
other pertinent studies—including Wright [1] and Siegel [2]—and to frame
the results with respect to existing knowledge. For example, while Young
et al’s results show a significant prevalence of males (about 2:1) in the
‘Goth’ category, Hodkinson—the only academic reference on Goth cited by
the authors (see Young et al, ref [5])—clearly states that the Goth
subculture is comprised of equal numbers of males and females. The
reluctance to address this inconsistency with respect to their own cited
reference is not only a significant oversight, it also makes it impossible
to determine whether the authors’ findings are the result of male over- or
female under-identification as Goth, or if they are simply symptomatic of
untenable sample size and study design.
In addition, while Young et al find females at risk of attempted
suicide, the known suicide rate for the 15-19yr group in 2000 was 4 to 1
with respect to males (see Young et al, ref [1]). Hence, the results
directly contradict what is logically expected.
Furthermore, it is notable that members of the Goth subculture
practice self-harm almost exclusively by means of cutting, scratching and
scoring, and not through more extreme methods such as punching or self-
poisoning. However, the authors unwillingness to consider the context(s)
in which cutting, scratching and scoring occur, along with their readiness
to subsume potentially diverse practices into a single discourse of
pathology, makes it impossible to draw conclusions about the meaning and
effects of these behaviours for the Goth subculture.
While the authors seek to link cutting, scratching and scoring to
depression, attempted suicide and psychiatric illness, these techniques
can in fact be practised for a range of different reasons. For example,
within some subcultural contexts, these practices are used to induce fine
scarring in decorative patterns on the body; that is, they are used as
methods of bodily decoration and adornment, much like tattooing or body
piercing. Without an understanding of context, it is impossible to
determine whether this is the case for the Goth subculture. However, the
tendency for medical and mental health discourse to systematically
misrecognise body modification as self-mutilation or self-harm has been
noted elsewhere [3].
Unfortunately, studies like the current one, which adopts an
epidemiological approach to assessing traits within subgroups, habitually
seem to support prevailing popular stereotypes. Perhaps this explains the
ready acceptance and promulgation of the findings, whilst disregarding the
lack of substantiation and generalisability, as well as the serious
methodological flaws.
[1] Wright R. I’d sell you suicide: pop music and moral panic in the
age of Marilyn Manson. Popular Music 2000; 19: 365-86.
[2] Siegel C. Goth’s dark empire. Bloomington: Indiana University
Press, 2005.
[3] Pitts V. Body modification, self-mutilation and agency in media
accounts of a subculture. In Body Modification (Ed. Featherstone M).
London: Sage, 2000, pp291-303.
Competing interests:
None declared
Competing interests: No competing interests
I take great exception to the views expressed by some of the
contributors, most "goths" in this country (Britain) are employed either
in the caring professions or other professions most are over 30 and have
long term partners and children. I myself am 46 years old and have never
self harmed in my life. To say "this group of misfits have no time for
standard issue mores of society" is an absolute insult. I go to goth
festivals, I do not as a woman have to worry about being subjected to
unwanted attention, drinks spiked or violence as depicted on our
television screens when clubs and pubs close.
This piece of research was carried out in small area and with a single age
group, any research student can tell you this is not the way to carry out
good research. Nor has the research looked at cause and effect ie do they
self harm because they are goths or have they become goth because they
self harm, the goth culture is an inherently inclusive non-judgemental
culture and this may be why it appears that self harmers are more likely to
be goth.
Competing interests:
None declared
Competing interests: No competing interests
This article interested me both from the perspective of co-ordinating
suicide prevention work aimed in part at local young people and I must
confess to having been a 'Goth' in Glasgow, Scotland back in the day (1982
-5).
From my understanding the original scene re-glamourised post punk UK
and it's legacy is still felt in some pretty prolific singers/songwriters
(Nick Cave, Gavin Friday, Siouxsie Sioux, Lydia Lunch, Robert Smith, The
Cocteau Twins - probably all of whom rightly shudder at the term). Like
most 'youth cults' it left a trail of substance use and wreckless sexual
abandon and visually expressed the doom-laden angst that eclipsed young
people in Thatcher's UK at the time. Has history repeated itself?
I'm unsure whether current identification as a 'Goth' relates to this
older term - I observe a current 'gothic look' but am aware of a HUGE
range of musical and cultural influences on this group in Glasgow alone;
Heavy Metal, Metal-Core, Death / Black metal, Emo, Hardcore, Grunge, Post-
rock, Math/tech-metal, Punk, Electroclash etc.
(any reader under 25 is probably cringing right now at my feeble
ramblings). The themes therein range from angst and despair, through
extreme personal pride, to stoned and drunken bliss and onwards to utter
rage. Sounding familiar? Teenage transition & turmoil experiences,
basically.
Either way, as a 'youth cult' it does exactly what it's intended to
do - bond and support young people beyond their family groups, create a
specific and timely language & culture and disturb/offend/perplex the
adult masses with at times transgressive acts and art. I worry that there
could be confusion and assumption here about key 'suicide' figures in
music; Derby Crash (The Germs), Ian Curtis (Joy Division) and Kurt Cobain
(Nirvana) especially - and our assumptions that depressed people making
depressive music equals depressed listeners. Since 1972 the NYC band
'Suicide' have confronted and terrify audiences with a synthesiser and a
microphone, utterly hated for the USE of the word - such is our fear.
Hunter S. Thomson tragically committed suicide last year, how do we now
relate to this great man's books?
I have also observed the ongoing hysteria in mainland Europe as young
'death & black metal' fans occasionally commit horrendous crimes
(murder, infanticide, arson) in small numbers, confirming adults worst
fears about the voodoo-like power of such music. The case of the 'West
Memphis Three' in the USA and the revealing HBO documentaries further
confirm this concern. It is of note, however that 'Gothic' music does not
feature in the 52 songs recently cited as the most depressing ever -
Billy Joel, Phil Collins and The Carpenters do however.
Are these findings concluding that vulnerable young people are self
harming and are DRAWN to this scene or are in greater numbers WITHIN this
group? Either way we must offer more information, support and hope to them
without dismantling, stigmatising and attacking the helpful peer support
element therein. FOSTER youth cult and groups in diversity, while
informing, supporting and valuing young people. My key and eventual
question would be - do we need a specific intervention? Gothbusters
anyone?
Further Unscientific Reading:
'I Hate Myself and Want To Die - the 52 most depressing songs ever
heard' - Tom Reynolds (Sanctuary)
'And the Ass Saw The Angel' - Nick Cave (Penguin)
'Suicide - No Compromise' - David Nobakht (SAF)
'Fear & Loathing - The Strange And Terrible Saga of Hunter S.
Thomson' - Paul Perry (Plexus)
'The Primal Screamer' - Nick Blinko (Spare Change)
'Lexicon Devil - The Fast Times and Short Life of Derby Crash and The
Germs' - Brendan Mullin / Don Bolles / Adam Parfrey (Feral House)
'Gavin Friday - The Light and The Dark' - Caroline Van Oosten De Boer
(Von B Press)
'American Hardcore - A Tribal History' - Steven Blush (Feral House)
'Black Coffee Blues'- Henry Rollins (2.13.61)
'Paradoxia: A Predator's Diary'- Lydia Lunch - Introduction by Hubert
Selby, Jr. (Creation)
'Lords Of Chaos - The Bloody Rise Of the Satanic Metal Underground' -
Michael Moynihan / Didrik Soderlind (Feralouse)
'Bowling For Columbine' - Dir. Michael Moore (2002) Miramax
'Paradise Lost 1 & 2 - The Child Murders at Robin Hood Hills' -
HBO Television / Warp Films (2005)
Competing interests:
None declared
Competing interests: No competing interests
These observations are from my own observations in San Francisco,
United States:
As I’m sure you noticed with your participant study about the Goth
Culture, the real key to this crew is extreme boredom. It’s spurned out of
a watered-down white (there are a few more 'minorities' in the Goth
Culture, but is overall 'white/caucasian') culture that offers nothing of
substance for a group of youths who are: highly imaginative, critically
intelligent (I've met quite a few Goths who were of remarkable
intellect/genius IQ & very well read), emotionally sensitive, socially
reclusive, and somewhat effeminate (the males). This combination makes
this bunch a group of ‘misfits’ that have no real use for standard issue
mores of society, and create their own mild ‘culture’. It is of no
surprise that this subculture has the highest rates. There isn’t one
shred of anything within the Goth Culture that encourages positive
behavior. The choice of drugs, clothing, hair styles, clubs, etc, are
designed to further distance themselves from ordinary society.
Heck, when you’re already depressed from any lack of interest in doing
anything (except shoot for being in a band or busting your butt to become
a significant artist), why not be enthralled with dying, -what other
really enticing choices are there? What Leaders/Governments don’t lie, or
what truly decent, non-soul-sucking careers exist (that you can be proud
of, and also have security in holding) anymore? The best thing this
culture has going for it is ‘safety in numbers’ and that is all.
Unfortunately, even within the Goth culture, there are serious codes of
conformity which smack of hypocritical display. They look almost
identical, dress accordingly for acceptance/identification, and listen to
the same music. They don’t want to be ‘bothered’, and prefer to be left
alone by society. I have never, ever seen a 'sober' Goth. Most Goths get
bored over time with the same old scene and realize their original
romanticized attraction was nothing more than a falsehood.
Most Goths make a humble (in rare cases, an excellent living) financial
career out of drug dealing. A few have their act together with decent
jobs in the computer fields. Some find their way into local theaters, or
appear somewhat ‘dressed down’ and playing in classical symphonies (I knew
of one that played the violin in a classical ensemble). The major
contribution this culture has added to mainstream society is a few good
music bands (Bowie, Bauhaus, Ministry, Sisters of Mercy, etc.).
Traditionally, they like staying up all night, sleeping all day and eat
speed/LSD/psychedelics/herion/Extasy more than common food alone (being
super-skinny is the ‘correct look’). A few have some very wealthy
families whom they ‘sponge’ cash from, and in turn, buy loads of dope for
their much poorer buddies (making them super popular/the elite) and can
also afford the nicest leather/latex gear above all others. The sex scene
(most are bi-sexual or gay) within the Goth culture is off the scales, and
most have unprotected sex (and it should be noted about the really
dangerous fascination with ‘vampirism’: what do you get when you mix
unprotected sex with ingesting another’s blood AND on lots of
drugs?.....Extreme stupidity and a short lifespan. Wouldn’t you kill
yourself if you found out you had HIV?! Not very sexy anymore!) I’d have
to say this bunch ought to be handed over the whole Porn Industry for
their extreme fascination of it. Between having a very advanced sexual
appetite, taking copious amounts of drugs, staying up all night, and dodge
EVER having to cope/socialize with common people, AND listen to music
which is totally depressing; how long will it be before catching HIV, one
or more VD’s, gaining a criminal record/getting busted for dope, and then
becoming so despondent from being bored after trying out every seedy and
sinful indulgence with a fried-out drug-addled mind, that there really
isn’t much left than other to kill yourself? I know of one 'Goth' that
committed suicide, but far more that contracted HIV and then AIDS. Also,
many had venereal diseases at one point or another. There is little
regard for protecting one's health. If you are perpetually 'depressed',
why care about what happens to you? This culture produces a massive
number of addicts. Along with the self-induced 'cuttings', these acts are
performed from a few impulsive sources: clinical depression, drug induced
from hallucinations, and 'blood-letting' from sucking their own blood, or
someone else sucking their blood (fantasy-based vampirism) during
concocted 'rituals' or combined with sex.
If you decide to do any further research on this culture, ask your
participants about how BORED they are with their own human race, and then
you’ll find the base reasoning of why there are subcultures (Punk, Hippie,
Goth, etc). They have simply tried to start their own (culture) from
whence there is none but cookie-cutter conformity which bores you to death
(debt, kids, poor paying job, college loans, etc) in the long run. Goth:
is essentially a group of bored, potentially depressed people who
gravitate to each other and create a wide variety of dangerous behaviors
and call it a subculture.
Competing interests:
None declared
Competing interests: No competing interests
Suicide: a psychiatric condition
The study conducted by the authors (1) no doubt have given new avenue
to the cultural and ethnic factors in suicide but it is definitely not
answering the biology behind the act of committing suicide. Apart from
this, study has also failed in discussing “Psychiatric condition” as one
of the major cause of suicide.
According to 1999 data from the Center for
Disease Control and Prevention, suicide was the eleventh leading cause of
death (homicide was fourteenth), and the third leading cause of death
between ages 15 and 24 years. The vast majority of people with suicidal
intent have a major psychiatric diagnosis. It has been estimated that 90%
or more of them can be shown to have a major psychiatric illness (2 &
3). Mann and colleagues (4) have proposed a stress-diathesis model of
suicidal behavior, as “a psychiatric disorder is generally a necessary but
insufficient condition for suicide”. The model posits that suicidal
behavior is a function of an individual’s threshold for suicidal acts and
the stressors that can lead to vulnerability.
The authors believe that the
threshold for suicidal acts is trait-dependent (diathesis), and is
mediated by factors such as aggression, impulsivity, substance abuse,
family history and low brain serotonin function. Stressors include
psychiatric illness and interpersonal problems. There are genetic and
biologic correlates of suicidality as well as the underlying psychiatric
illnesses that are often associated with suicidal behavior. Low serotonin
levels may be the underlying feature of suicidal behavior, aggression and
substance abuse (4). Hyper intensities in the basal ganglia may be at
higher risk for mood disorders and suicide attempts secondary to
interference in neuroanatomic pathways. These pathways may be crucial to
mood regulation (5). A number of these studies have found an association
between reduced serotonin function, including low levels of the serotonin
metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid
(CSF), with impulsivity, violence and suicide (6 & 7). Low CSF 5- HIAA
levels may also predict future suicide attempts (8).
Aggressive behavior
and, independently, suicidal behavior, may have impulsivity as a common
denominator, which may be mediated by serotonergic dysfunction (5). A
number of psychiatric diagnoses are linked with suicidality. While
patients with mood disorders (major depression and bipolar disorder) are
commonly assessed for suicidality, anxiety disorders are also associated
with significant suicide risk. Psychosis, in both mood disorders and
schizophrenia, can heighten risk. Although borderline personality disorder
has a high prevalence of suicidal ideation, impulsivity and self-injurious
behavior, these patients are at risk for unexpected intentional and
accidental death.
REFERENCE
1. Young R, Sweeting H, West P (2006) Prevalence of deliberate self harm
and attempted suicide within contemporary Goth youth subculture:
longitudinal cohort study BMJ 2006;332:1058-1061 (6 May),
doi:10.1136/bmj.38790.495544.7C (published 13 April 2006)
2. Henriksson MM, Aro HM, Marttunen MJ et al. (1993) Mental disorders and
comorbidity in suicide. Am J Psychiatr 150(6), 935–940.
3. Mann JJ (2002) A current perspective of suicide and attempted suicide.
Ann Int Med 136(4), 302–311.
4. Mann JJ, Waternaux C, Haas GL et al. (1999) Toward a clinical model of
suicidal behavior in psychiatric patients. Am J Psychiatr 156(2), 181–189.
5. Ahearn EP, Jamison KR, Steffens DC et al. (2001) MRI correlates of
suicide attempt history in unipolar depression. Biol Psychiatr 50(4),
266–270.
6. Mann JJ (1998) The neurobiology of suicide. Natl Med 4, 25–30.
7. Placidi GP, Oquendo MA, Malone KM et al. (2001) Aggressivity, suicide
attempts, and depression: Relationship to cerebrospinal fluid monoamine
metabolite levels. Biol Psychiatr 50(10), 783–791.
8. Roy A, De Jong J and Linnoila M (1989) Cerebrospinal fluid monoamine
metabolites and suicidal behavior in depressed patients. A 5-year follow-
up study. Arch Gen Psychiatr 46, 609–612.
Competing interests:
None declared
Competing interests: No competing interests