Pactes suicidaires : une revue de la littérature

Abstract

Suicide pacts are a mutual arrangement between more often two people who decide to kill themselves together, usually in the same place. After a presentation of some famous cases (Mayerling tragedy, double suicides of Heinrich Kleist, Stefan Zweig, Max Linder or Paul Lafargue), this article describe the epidemiology, circumstances and motivation, mental health, main differential diagnosis, psychopathology and legal issues in suicide pacts. These pacts are relatively rare, between 0.56 and 2.5% of all suicides in reference occidental studies. They are classically more frequent (4%) in Japan. The common romantic view of pacts between lovers unsuccessful in their marriage project, up to 58% of cases in a study in Japan, characterizes only a minority in Occident (6.4 to 20%). These pacts involve more often married couples (70 to 78%), average age being between 51 and 56 years. Couples of aged husbands, depressive, mutually devoted and socially isolated, suffering from physical debiliting or painful illness, are usually concerned. Parents and children, siblings or sometimes friends can also be implicated in suicide pacts. The threat of dissolution of a close, affectionate and exclusive relationship between both partners, one of them being dominant and becoming the instigator of a double suicide, is emphasized by some authors. Such suicide pacts may also occur between persons unknown to themselves before, sparing their difficulties in life on Internet and searching one or more partners to die together. Couples use preferentially the same non-violent method for death, above all intoxication by carbon monoxide from car exhausts or medicines in recent series in England and Wales (89 to 92%). Different means such as submersion, poisoning by other liquid or solid substances, jumping and suffocation can also be used. Firearms are more commonly in cause in homicide-suicide pacts. Considering psychopathology, major depressive disorder of one or both members of the couple seems the most frequent diagnosis, in a context of anxiety or pain related to illness or handicap, financial difficulties and a possible separation. Suicide pacts have also common characteristics with induced psychosis or “folie à deux”, with an exclusive bonding between these persons, social isolation and shared delusive thoughts of financial ruin or disease. In a forensic point of view, differential diagnoses are especially homicides-suicides without the consent of the victim, double or multiple homicides or accidental consequences of a suicide. Most legislations in many countries punish complicity or assistance to suicide and more over homicide. The fact that these suicide pacts are carefully premeditated and frequently lethal must arouse clinicians' attention to patients wishing or having already tried to die together.