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To the Editor: Recent articles have described use of the Internet by individuals to obtain instructions on how to complete a suicide (1, 2). Editorials and discussions have focused on the existence of these sites and the information they provide (3, 4). What is lacking is information on the characteristics of individuals who access these sites. I report the case of another individual who used the Internet to research suicide methods.
Mr. A was a 20-year-old man who was admitted to the hospital after his mother expressed her concerns about his suicidal thoughts. On his initial interview, he reported no symptoms of depression. He had been admitted previously after a suicide attempt in which he overdosed on codeine that was distilled from an acetaminophen-based product. He reported that he found this procedure on the Internet. He was treated with an antidepressant, a mood stabilizer, and a second-generation antipsychotic. He discontinued his medications after discharge and refused to come in for outpatient follow-up. Shortly after the current admission, he left the hospital without permission. During this absence, he purchased the necessary equipment to commit suicide by helium asphyxiation but returned to the hospital without attempting self-harm. He reported that he had identified this method of suicide on the Internet. He subsequently endorsed symptoms of depression and was treated with citalopram. Additionally, he was diagnosed with narcissistic personality disorder by myself, was noted to have a high IQ (superior range), and used a rigid interpretive style characterized by intellectualization and rationalization. He responded to pharmacotherapy but was difficult to engage in a psychotherapeutic relationship. He was discharged with follow-up by a psychiatrist who works extensively with young adults.
The Internet has become a ubiquitous source of information for both professionals and patients alike. A large number of web sites and discussion groups provide information identifying methods of self-harm. Of the methods described in this case, I was able to locate the latter easily. What is less clear is information detailing how frequently patients use these resources and potential features that would allow at-risk individuals to be identified. Since the methods described on the Internet are potentially more lethal, being able to identify this group accurately is crucial in risk assessment. The number of reported cases is small. In three cases (reference 2 and this letter), patients were diagnosed with personality disorders or borderline mental retardation, indicating that they likely would use rigid, concrete, or maladaptive coping strategies. Creating a profile associated with individuals using Internet-derived suicide plans will require more study. In the meantime, clinicians should be alert to the dangers of Internet use by their suicidal patients.
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