The sudden, sad news of Mark Madoff’s suicide at the age of 46 while embroiled in as many as nine lawsuits against him and his family was not entirely unexpected and also somewhat unsurprising. From a clinical point of view, Mr. Madoff was at moderate to high risk for suicide or self-inflicted injury, but also benefited from several “protective factors” that could have made his choice of suicide less likely.
Nonetheless, the barrage of news that portrayed him as under investigation for being his father’s accomplice (without any indictment), his having become virtually unemployable, the shame of being a Madoff in a world where the surname has become a synonym for a crime of epic proportions eventually proved too much to bear. Mr. Madoff’s options progressively narrowed to one single choice which he exercised alone in his Manhattan apartment in the early hours of a Saturday morning: death by suffocation.
The pressure of the last two years weighed on him enormously… He was deeply, deeply angry at what his father had done to him — to everybody. That anger just seemed to feed on itself… That’s why I never believed he knew about the fraud. He was always a nervous wreck. He could never have stood it — keeping a secret like that would have torn him apart. –- Statements by Mark Madoff’s friends to the New York Times
Was the last straw his wife Stephanie’s application to the courts to have her last name and that of her two children changed to “Morgan”? Was there an early sign in his October 2009 disappearance, when he was eventually located at the Soho Grand Hotel, in a single room, alone with his thoughts and, some say, a weapon nearby?
By all current standards of risk for self-injury or suicide, Mr. Madoff was a danger to himself. The risk factors for suicide, according to the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention are:
- A family history of suicide
- A family history of child maltreatment
- Previous suicide attempt(s)—was the Soho Hotel episode a precursor?
- A personal history of mental disorders, particularly clinical depression—Mr. Madoff was reportedly prone to depressive mood swings and physical ailments, including stomach troubles; also, Mr. Madoff had always seemed sensitive to criticism and tended to take his grievances too much to heart
- Alcohol and substance abuse
- Feelings of hopelessness—unsurprising given the relentless drumbeat of negative news, the literal and figurative loss of identity that had beset Mr. Madoff for the last several years
- Isolation, a feeling of being cut off from other people
- Impulsive or aggressive tendencies—Mr. Madoff was said to be deeply, deeply angry at his father and at everyone else
- Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
- A local epidemic of suicide
- Barriers to accessing mental health treatment
- Loss (relational, social, work, or financial)—Mr. Madoff had lost his job, the only one he had ever had, when his father’s firm was shut down and had no prospect to find employment
- Physical illness
- Easy access to lethal methods—Mr. Madoff first tried the vacuum cleaner cord, which broke, then his dog’s leash, which proved to be sufficiently strong
- Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts
On the other hand, the protective factors that can make suicide a less likely choice are:
- Effective clinical care for mental, physical, and substance abuse disorders
- Easy access to a variety of clinical interventions and support for help seeking—after the Soho Hotel episode Mr. Madoff had obtained counseling, which seemed to have steadied him
- Family and community support (connectedness)—Mr. Madoff was happily married and had two small children, in addition to two children from a previous marriage, and was well-connected with a network of childhood, school and business friends
- Support from ongoing medical and mental health care relationships
- Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
- Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
Clearly, a diagnosis of Mr. Madoff’s true mental state and whether he benefited from any of these protective factors and to what extent he may have been at risk is impossible to make by reading news reports and at a distance. His death makes a specific statement that trumps all other assertions of low risk or protective factors. As well-connected and potentially as well-supported as Mr. Madoff was, ultimately he found himself literally alone to face the only choice that to him seemed to offer an escape from a life that had lost its meaning and its anchoring points of identity and hope for the future.