(C) Our World in Data
This story was originally published by Our World in Data and is unaltered.
 . . . . . . . . . .



Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies [1]

['Yoshimasu', 'Department Of Hygiene', 'School Of Medicine', 'Wakayama Medical University', 'Wakayama', 'Kiyohara', 'Department Of Preventive Medicine', 'Graduate School Of Medical Sciences', 'Kyushu University', 'Fukuoka']

Date: 2008-09-24  

As strategies for effective suicide prevention, two main models have been advocated [43]. Figure 3 shows the results of the present analyses applied to these two models. One is called the disease or simple model, which has been emphasized by clinicians, especially by psychiatrists [43]. This model means suicides are caused by mental disorders, mainly by depression. Thus, secondary prevention of the depression is regarded as greatly important.

Fig. 3 Two models of suicidal pathway Full size image

The other is an interactive model based on the concept of health promotion in which a comprehensive approach, partnership among concerned groups, construction of network system, and suicide prevention program at the small community level are important [43]. Recently, from the public health points of view, this interactive model has been more evaluated for building up an effective strategy for suicide prevention than the disease model. The four personal and social factors included in the present meta-analyses are also considered to affect each other. A suicide attempt is reversible, but it is directly connected with the completed suicide. So it can be put beyond the interactive limits of the other four factors. This model is also associated with the primary prevention of depression.

Many suicide victims are considered to be in a depressive state when they take suicidal action. However, as mentioned above, depression is mediated by several social factors and other mental disorders. Chronic alcohol/substance dependence or social isolation, such as divorce or unemployment, makes a depressive state worse. Furthermore, a worse depressive state makes persons more likely to abuse alcohol or illicit drugs, and consequently lead them to divorce or dismissal. Such a vicious circle should be eliminated if possible even in the clinical setting. Thus, even clinicians or co-medical staffs should not be too much concerned about early detection or treatment of only depression for the prevention of suicide. They should also examine the patients’ social backgrounds.

The present meta-analyses using studies by psychological autopsy revealed that five representative social and personal factors were associated with more or less significantly increased suicidal risk.

The psychological autopsy method involves several ethical issues [15]. Interviewing subjects who have recently lost their family member might lead to traumatic, anxiety- and guilt-provoking situations, and would sometimes thus be conducted in chaotic conditions. The psychological autopsy is usually conducted between 3 and 12 months after the suicide, in order to permit time for bereavement [15]. Many interviewers make the first approach very carefully, for example, by letter. However, whether the timing is right or wrong for contacting a bereaved family, much depends on the cultural set of values in each country or ethnic group. For instance, contact with the bereaved family of suicide victims is considered somewhat taboo in Japan. Furthermore, the bereaved family often wishes to conceal the fact that their close relative died by suicide. This may be the major reason why psychological autopsy studies have not been conducted in Japan.

Another ethical problem is the belief that the integrity of the deceased must be respected. This may sometimes be difficult, especially when the deceased suffered from a personality disorder or substance dependence. Unfortunately, as mental disorders are sometimes distorted by prejudiced opinion, these are often great obstacles to psychological autopsy. This matter also depends much on the cultural set of values in each country. This problem is also connected with the later-mentioned “heterogeneity” among the studies included in the present meta-analyses.

Limitations

Suicide itself is strongly affected by cultural differences and value systems. In Christian countries, for example, suicide is regarded as a sin. On the other hand, in Japan, suicide has been traditionally glorified in one aspect as traditional “Bushido.” There are some extremists in specific new religious groups who endorse suicide as holy behavior. These differences in sense of value regarding suicide in various ethnic groups are of course closely connected with attitudes against suicidal risk factors, especially social factors [32]. This is a major limitation in the present meta-analyses in which groups from different cultures are included, although relatively common risk factors were selected. Indeed, as mentioned above, the Q statistics for the assessment of heterogeneity for all the risk factors proved to be statistically significant.

Another methodological limitation is that the simultaneous adjustment for several risk factors that are different in each study is impossible in meta-analysis. As mentioned above, several suicidal risk factors interact with one another, as seen in the example of alcohol dependence and depression, and the interactive model has been evaluated for building an effective strategy for suicide prevention. A statistically more adequate method, such as pooled analysis combining the original data, may be necessary for solving this problem. Furthermore, we had no choice but to neglect the original matching sampling of case-control design because only crude ORs calculated from 2 × 2 cross tables can be synthesized by meta-analyses. In this regard, the used effects in our meta-analyses may be somewhat distorted compared with the original ones and, therefore, should be carefully interpreted.

In the present study, sub-analyses for the specific population such as male or female, young or elderly did not show a clear association between relevant risk factors and suicide. A key reason is that the data available on these sub-groups were too few to obtain conclusive results. However, effects of some risk factors are obviously different according to the target population. For example, it is probable that socio-economic factors such as unemployment status may not cause stress in elderly people. On the other hand, the complex of somatic and mood disorders may be a critical problem in the elderly because the incidence rate of somatic disorders increases as they grow old [44].

Finally, there may be some studies that could not be characterized by the keywords used in the present study, but conducted with designs similar to psychological autopsy studies. Because “psychological autopsy” is a special technical term, it actually reduces the number of relevant articles searched by keywords. This means that some biases may be included in the process of study selection. Furthermore, the direction of this selection bias is unclear.

Future direction

In spite of the above-mentioned limitations, the present results for each risk factor suggested the importance of identifying a high-risk group in light of the interactive effects of several risk factors. Among the five risk factors included in the present study, depression and previous suicidal attempt or deliberate self harm behavior are most strongly associated with suicide. These factors are closely connected with one another. Persons with both depression and previous suicidal attempt must be regarded as the highest risk group, and sufficient medical and social care should be supplied. They are easily regarded as a high-risk group in the medical setting. However, the effects of other environmental factors also should not be overlooked. Adequate family or social support may relieve the suicide risk in those people. An intervention study in a Japanese rural area with a high suicide rate suggested that the establishment of social capital is most important for suicide prevention [45]. Social capital means attachments to the community and relationships of mutual trust among people by reinforcing the network system among persons or groups in the community. Social isolation caused by divorce or unemployment is the very opposite of complete social capital.

The results of present meta-analyses suggested that both personal and social factors were associated with suicidal risk. This means a comprehensive approach is necessary for effective suicide prevention, but one must never underestimate the importance of secondary prevention of depression. Surely, depression is observed in many persons who commit suicide. Conventional and useful screening methods for depression are required especially in the clinical setting of community or workplace [46]. However, at the same time, the comprehensive viewpoint should not be downplayed in the public-health setting. Of course, this comprehensive (interactive) model works well for the prevention of suicide on the condition that the adequate model for each specific population, e.g., young or old, male or female, is established. Social and cultural factors may be underlying gender differences in the suicide rate; the rate for men is higher than women in many countries [47].

In this regard, a suitable prevention model among clinically specific populations, such as those with schizophrenia, should also be made. As mentioned in the “Methods” section, patients with schizophrenia are very few in the general controls. It is clinically more significant to clarify which factors, e.g., some specific symptoms or social factors, are associated with suicidal risk in patients with schizophrenia rather than verifying that schizophrenia itself is a risk factors for suicide. Factors related to suicidal risk in such a specific population can be extracted by using controls with the same diagnosis but without completed suicide or suicide attempt. For instance, symptoms related to suicide in patients with a major depressive disorder were revealed by comparing the patients of suicide victims with living patients as controls [48].

In the present Japanese circumstances, the success or failure of the establishment of the social capital depends heavily on the characteristics of the communities on which the social network can be developed. Establishment of the universal methodology is also needed. Furthermore, as mentioned in the “Limitations” section, suicide itself and its risk factors are strongly affected by the cultural mindset. To obtain the exact evidence, psychological autopsy studies in Japan should be conducted with careful consideration of the characteristics of Japanese culture. Needless to say, such studies must also be accompanied by due ethical considerations for suicide victims and bereaved families.

[END]
---
[1] Url: https://link.springer.com/article/10.1007%2Fs12199-008-0037-x

Published and (C) by Our World in Data
Content appears here under this condition or license: Creative Commons BY.

via Magical.Fish Gopher News Feeds:
gopher://magical.fish/1/feeds/news/ourworldindata/