Last Words

Dr. Rahel Eynan is a researcher with Lawson Health Research Institute who has dedicated her life to studying the nature of suicide and those affected. 

She is the lead author on a study recently published in Suicide and Life-Threatening Behavior by The American Association of Suicidology. A first of its kind in the world, this study retrospectively compared the psychosocial and clinical characteristics of people who have died by suicide and left an E-note with those who left a paper note, or no note at all. 

“Suicide notes are intimate last communications left by suicide decedents to their loved ones, friends or foes,” explains Dr. Eynan. Only a minority of suicide decedents leave a suicide note, which is defined as a message expressed by a person who intends to end their life. 

Typically, the notes are handwritten on paper, walls, body parts or mirrors. However, electronic suicide notes have been reported with increasing frequency including communication through email, text messages, tweets, blogs, video sharing websites, chat rooms and posts on social media networks. 

This emerging phenomenon remains generally under-researched. 

“The notes play an important role in forensic investigations and have evidentiary value in the courtroom. They are also considered integral to understanding suicidal behaviour as they provide a unique opportunity to examine an unsolicited account of the person’s thoughts and emotions prior to the self-destructive act,” says Dr. Eynan. 

This study was embedded in the Southwestern Ontario Suicide Study (SOSS) and was conducted  in collaboration with the Office of the Chief Coroner and Ontario Forensic Pathology Services and the London regional coroner office. The researchers collected data for 476 deaths by suicide that occurred between January 2012 and December 2014. Socio-demographic, psychosocial and clinical characteristics were collected with a modified version of the Manchester questionnaire used in the UK. 

“Note leaving does not appear to be a random phenomenon among suicide decedents. There are common characteristics between those that do offer a final communication and in what form,” states Dr. Eynan.

They found that final communication was left by 45.8 per cent of the individuals and of those almost 75 per cent left notes that were handwritten or typed. Electronic notes were left by 17.9 per cent, usually in the form of text messages, and 7.8 per cent left a combination of paper and electronic notes, as some people left more than one. Some notes contain a just a single word while others were several pages in length. 

The average age of suicide decedents is 47.2 years old and the majority are men. Death by suicide often happens after a major life transition, including those involving finances, business and employment or the dissolution of a marriage or relationship. In some cases, it is associated with a mental illness. 

Those who did not leave a note were more likely to have had a diagnosed mental disorder; histories of self-harm; other physical illnesses; previous admissions to hospital or mental health services; and, been assessed for suicide behavior 3 months prior to their death.

People who left a note were significantly younger in age; more likely to be divorced or separated; less likely to be living with a partner; and, less likely to have been retired. 

“Suicide decedents with fewer than two admissions to a mental health unit, including those with no history at all, were three times more likely to have left a suicide note,” explains Dr. Eynan. “Two-thirds of these people however did have contact with a primary health care provider in the month prior to their deaths. Interestingly, most were for routine and non-urgent reasons.”

Suicide notes are written for several purposes. It can be an opportunity to put affairs in order, justify or explain their suicidal action, or reduce the emotional burden of those left behind. 

It can be theorized that people without a diagnosis of mental illness and fewer health care admissions may be more compelled to complete their suicide narrative and explain their motives. On the other hand, those who did not leave notes may have felt that their long-standing struggles with mental illness were well known to family and friends. 

The findings point to a subgroup of younger suicide people who have less contact with mental health services, have no mental illness and yet are at risk of suicide. 

“This tells us that we can be more proactive in assessing for suicidal behaviours at each interaction of help-seeking and health care.” For example, routinely giving screening questions at every appointment which assess mood and other indicators. “It could be something like a paper form or tablet in the waiting room, reducing the stigma and more easily opening up the conversation,” adds Dr. Eynan. 

The general public should also be educated to take any communication by any means of suicide risk or intent as serious.

The shifting methods of communicating final good-byes that make use of newer forms of technologies could provide a window of opportunity for intervention. Social media sites and app developers could partner with researchers to develop innovative protocols and mechanisms that identify users at risk and intervene by sending the user links to crisis services or directly connecting them to an appropriate service.

Dr. Eynan is often reminded of the quote ‘whoever saves a life, saves an entire world.’ She takes the utmost care to treat each person’s story with dignity and respect. 

“There was a lot of suffering shared in the notes, but the most prevalent messages were expressions of love.”  

While this kind of research can be difficult, it gives her a lot of hope. 

If you need help:

Canadian Mental Health Association’s Reach Out program is a 24-7 telephone hotline and internet service for individuals experiencing mental health concerns, addictions or crisis.

Reach Out can be contacted at 519-433-2023, toll free at 1-866-933-2023 or online at www.reachout247.ca.