Suicidal Behaviour

Suicidal Behaviour: Underlying dynamics is a wide ranging collection of articles

that builds upon an earlier volume by the same editor, Suicidal Behaviour:
Assessment of people-at-risk, 2010, and delves deeper into the dynamics of suicide
by synthesizing significant psychological and interdisciplinary perspectives. The
volume brings together varied conceptualizations by scholars across disciplines
from around the globe, adding to available theoretical understanding as well as
providing research-based inputs for practitioners in the field of suicidal behaviour.
The book has sixteen chapters divided into two broad sections, opening with a
discussion of the theoretical underpinnings of suicidal behaviour in the first half,
conceptualizing the phenomenon from different vantage points of genetics,
personality theory, cognitive and affective processes, stress and assessment
theories. The second half brings in varied research evidences and assessment
perspectives from different populations and groups, building on theoretical
foundations and discussing the nuances of dealing with suicidal behaviours among
sexual minority populations, alcoholics, military personnel, and specific socio-
cultural groups. It closes with a focus on a significant issue encountered often in
clinical practice – assessment of suicide risk and ways of resolving the cultural,
ethical and legal dilemmas.

Updesh Kumar is a Scientist ‘F’ and Head, Mental Health Division, Defence
Institute of Psychological Research, the Defence Research and Development
Organization (DRDO), New Delhi, India.
This page intentionally left blank
Suicidal Behaviour
Underlying dynamics

Edited by
Updesh Kumar
First published 2015
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2015 U. Kumar
The right of the editor to be identified as the author of the editorial material,
and of the authors for their individual chapters, has been asserted in accordance
with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilized in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the
publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without intent
to infringe.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
pages cm
1. Suicidal behavior—Risk factors. I. Kumar, Updesh.
RC569.S8954 2015
616.85v844505—dc23
2014019822

ISBN: 978-1-138-79381-1 (hbk)

ISBN: 978-1-315-76084-1 (ebk)

Typeset in Galliard
by RefineCatch Limited, Bungay, Suffolk
To His Holiness Sri Sri Ravi Shankar Ji
Founder, Art of Living
This page intentionally left blank
Contents

List of contributors ix
Foreword xix
MAURIZIO POMPILI
Preface xxi

PART I
Theoretical underpinnings 1

1 Conceptualizing suicidal behaviour:

understanding and prevention 3
HARDEEP LAL JOSHI, VIJAY PARKASH AND UPDESH KUMAR

2 Genetics of suicidal behavior 23

MARCO SARCHIAPONE AND MIRIAM IOSUE

3 Suicidality and personality: linking pathways 39

VIJAY PARKASH AND UPDESH KUMAR

4 Emotion dysregulation and suicidality 56

MICHAEL D. ANESTIS

5 Role of aggression and impulsivity in

suicide attempts and in suicide completion 66
YARI GVION AND ALAN APTER

6 Psycho-social stress and suicidal behaviour 80

VSEVOLOD A. ROZANOV

7 From social adversity to psychological pain:

a pathway to suicide 98
PHILIPPE COURTET AND EMILIE OLIÉ
viii Contents
8 Clustering and contagion of suicidal behaviour 110
ELLA ARENSMAN AND CARMEL McAULIFFE

PART II
Varied research evidence and assessment perspectives 121

9 Suicidal ideation and behavior among

sexual minority youth: correlates, vulnerabilities,
and protective factors 123
SAMANTHA PFLUM, KAITLIN VENEMA, JOSEPH TOMLINS,
PETER GOLDBLUM AND BRUCE BONGAR

10 Spatial and temporal distribution of suicidal

behaviour with a special focus on Hungary:
understanding the variations 136
ZOLTÁN RIHMER, XENIA GONDA AND PETER DOME

11 Suicide in the United States military 153

TRACY A. CLEMANS AND CRAIG J. BRYAN

12 Contribution of alcohol to suicide mortality

in Eastern Europe 168
YURY E. RAZVODOVSKY

13 Media content representation of suicide in

various societies: a critical review 186
QIJIN CHENG AND PAUL S. F. YIP

14 The formal assessment of suicide risk 202

BRUCE BONGAR, ELVIN SHEYKHANI, URI KUGEL
AND DAVID GIANNINI

15 Culturally competent suicide assessment 213

URI KUGEL, LORI HOLLERAN, KASIE HUMMEL,
JOYCE CHU, PETER GOLDBLUM AND BRUCE BONGAR

16 Ethical and legal issues in dealing with

suicidal behaviour 224
SWATI MUKHERJEE AND UPDESH KUMAR

Index 236
Contributors

The Editor
Updesh Kumar, PhD, is Scientist ‘F’ and chair of the Mental Health Division at
the Defence Institute of Psychological Research (DIPR), R&D Organization,
Ministry of Defence, Delhi. He obtained his doctorate degree in the area of
suicidal behaviour from Punjab University, Chandigarh and has 23 years of
experience as a scientist in R&D organizations. He specializes in low intensity
conflict, suicidal behaviour and terrorism research. He edited six volumes:
Recent Developments of Psychology, Counseling: A practical approach, Suicidal
Behaviour: Assessment of People-at-Risk (Sage Publications, 2010), Countering
Terrorism: Psychosocial Strategies (Sage Publications, 2012),Understanding
Suicide Terrorism: Psychosocial Dynamics (Sage Publications, 2014), and
recently Positive Psychology: Applications in Work, Health and Well-being (in
press, Pearson Education). He has written the manuals Suicide and Fratricide:
Dynamics and management for defence personnel, Managing Emotions in
Daily Life and in Work Place for general publication, Overcoming Obsolescence
and Becoming Creative in the R&D Environment for R&D organizations
and Self-Help Techniques in Military Settings. He has written more than
50 other academic publications in the form of research papers, journal articles
and book chapters and represented his institute at national and international
level. Dr Kumar has been a psychological assessor (psychologist) in various
services selection boards for eight years for the selection of officers in the
Indian armed forces. He is certified by The British Psychological Society with
level A and level B Certificate of Competence in Occupational Testing. He has
to his credit many important research projects relating to the armed forces.
He was conferred with the DRDO’s Best Popular Science Communication
Award, 2009 by the Honourable Defence Minister of India. He has also been
the recipient of the DRDO Technology Group Award in 2001 and 2009,
Professor Manju Thakur Memorial Award, 2009 and 2012 by the Indian
Academy of Applied Psychology (IAAP) and Professor N. N. Sen Best Paper
Award for the year 2010 by the Indian Association of Clinical Psychologists
(IACP). The Indian government recently conferred the Laboratory Scientist
of the Year Award, 2012–2013 and the prestigious DRDO’s Scientist of the
Year Award, 2013.
x List of contributors

Contributors
Michael D. Anestis, PhD, is Assistant Professor and Director of Suicide and
Emotion Dysregulation Laboratory, Department of Psychology, University of
Southern Mississippi, USA. His work focuses primarily on risk factors for
suicidal behaviour and efforts to empirically test widely held assumptions
about suicide. He has published numerous journal articles in the field of
suicidal behaviour in Suicide and Life-Threatening Behaviour, Journal of
Psychiatric Research, Journal of Affective Disorders, Archives of Suicide Research,
Personality, Behaviour Research, Clinical Psychology Review and Therapy and
Mental Health. He is the author of several book chapters in the area of suicidal
behaviour published by the Oxford University Press and Guilford Press. He
has been the reviewer of various international journals of suicidal behaviour
and clinical psychology. He is affiliated to various professional societies like the
American Association of Suicidology (AAS) and Military Suicide Research
Consortium (MSRC) and is the recipient of Resident Outstanding Contribution
to the Consortium Award 2011 and Leonard Krasner Student Dissertation
Award 2009.
Alan Apter, MD, is Professor of Psychiatry at the Sackler School of Medicine at
the University of Tel Aviv, where he served as Chair of the department. He is
also the director of the Feinberg Child Study Center at Schneider Children’s
Medical Center of Israel, a member of numerous professional societies and
organizations and has published more than 300 articles and chapters as well as
two books. He is a member of the Israel government inter-ministerial
committee on suicide prevention and is also an adviser on suicide prevention
to the Israel Defense Force and a recipient of the American Foundation for
Suicide Prevention’s Distinguished Investigator Award.
Ella Arensman is Professor and Director of Research with the National Suicide
Research Foundation (NSRF) and Adjunct Professor with the Department
of Epidemiology and Public Health, University College Cork, Ireland. She
has been involved in research and prevention into suicide and self-harm over
the last 25 years, with a particular emphasis on risk and protective factors
associated with suicide and self-harm, cross-cultural differences, clustering and
contagion of suicidal behaviour, and effectiveness of suicide prevention and
self-harm intervention programmes. In Ireland, she played a key role
in developing Reach Out, the National Strategy for Action on Suicide
Prevention (2005–2014). She has been involved in many international
research consortia, such as the European Alliance against Depression (EAAD)
and Optimising Suicide Prevention Programmes and their Implementation
in Europe (OSPI-Europe).
Bruce Bongar, PhD, ABPP, FAPM, is the Calvin Professor of Psychology at Palo
Alto University, California and Consulting Professor of Psychiatry and the
Behavioral Sciences at Stanford University School of Medicine. He is a past
president of the Section on Clinical Crises and Emergencies of the Division of
 List of contributors xi
Clinical Psychology of the American Psychological Association, a diplomat of
the American Board of Professional Psychology, and a distinguished fellow
of numerous psychological organizations. He has won the Edwin Shneidman
Award for outstanding early career contributions to suicide research, the
Louis I. Dublin award for lifetime achievement in suicidology research, and
the Florence Halpern award for distinguished contributions to the practice of
clinical psychology. His research and published work reflect his interest in the
wide-ranging complexities of therapeutic interventions with difficult patients
in general, and in suicide and life-threatening behaviours in particular.
Craig J. Bryan, PsyD, ABPP, is a board-certified clinical psychologist in cognitive
behavioural psychology, and is currently the Associate Professor/Director of
the National Center for Veterans’ Studies (NCVS) at The University of Utah,
USA. He is on the Board of Directors of the American Association for
Suicidology and is considered a leading national expert on military suicide.
He is a consultant to the Department of Defense for psychological health
promotion initiatives and suicide prevention and has briefed Congressional
leaders on these topics. He regularly provides training to clinicians and medical
professionals about managing suicidal patients and has authored over
60 scientific publications and book chapters, including the book Managing
Suicide Risk in Primary Care. For his contributions to military suicide
prevention, posttraumatic stress disorder, and traumatic brain injury, he was
recognized in 2009 by the Society for Military Psychology with the Arthur W.
Melton Award for Early Career Achievement and in 2013 by Psychologists in
Public Service with the Peter J. N. Linnerooth National Service Award.
Qijin Cheng, PhD, is a postdoctoral fellow at HKJC Centre for Suicide Research
and Prevention, the University of Hong Kong and Adjunct Senior Instructor
in the Department of Psychiatry, University of Rochester Medical Center,
USA. Her research focuses on suicide, media and social context. She has
published in the Lancet, BMJ, Journal of Clinical Psychiatry, Journal of
Affective Disorders and BMC Public Health. She was a journalist before
pursuing her PhD and is devoted to promoting better cooperation between
suicide prevention professionals and media professionals.
Joyce Chu, PhD, is Assistant Professor at Palo Alto University, USA. She earned
her BA and MA in psychology at Stanford University, her PhD in clinical
psychology from the University of Michigan, and did a postdoctoral fellowship
at the University of California, San Francisco. Her specialties include geriatrics,
ethnic minority populations and diversity. Her research is focused around
understanding and improving mental health services for ethnic minority
individuals with depression, suicide, particularly among older adults and Asian
Americans.
Tracy A. Clemans, PhD, is a research psychologist with the National Center for
Veterans’ Studies (NCVS), University of Utah. She works collaboratively with
the Associate Director of NCVS, on military and veteran-related research
xii List of contributors
projects, publications and national presentations. From 2010 to 2012, she
completed a postdoctoral fellowship at the University of Texas Health Science
Center, where she worked as a research therapist with STRONG STAR, a
PTSD Research Consortium funded by the Department of Defense. She serves
as a consultant on the VISN 19 MIRECC Suicide Consultation Service,
providing suicide and psychological assessment to veterans considered to be at
risk for suicide. In addition, she provides individual psychotherapy with
veterans with PTSD, substance abuse/dependence and suicidality.
Philippe Courtet, PhD, is Professor of Psychiatry at the University of Montpellier,
and Head of the Department of Emergencic Psychiatry at the Academic
Hospital, Montpellier, France. His areas of interest and expertise involve vul-
nerability to suicidal behaviour, genetics and brain imaging of suicidal behav-
iours, bipolar disorders and eating disorders. He is president of the French
Association of Biological Psychiatry and Neuropsychopharmacology, chairman
of the suicide network of the European College of Neuropsychopharmacology
(ECNP), chairman of the task force ‘suicide’ of the World Federation of
Societies of Biological Psychiatry (WFSBP), and he was the President of the
Local Organizing Committee of the 2013 Congress of the European
Psychiatric Association (EPA). He has published about 100 articles in the field
of suicidal behaviour in peer-reviewed journals, including Archives of General
Psychiatry, American Journal of Psychiatry, Molecular Psychiatry and Biological
Psychiatry. He is author of several book chapters and editor of two books on
suicidal behaviour in France.
Peter Dome, PhD, received his medical diploma in 2000 at the Semmelweis
University, Budapest, Hungary. Until 2007 he worked as a psychiatric resident
and – after 2006 – as a psychiatrist at the National Institute for Psychiatry and
Neurology, Budapest. Since 2007 he has been a psychiatrist and a researcher
at the Department of Clinical and Theoretical Mental Health, Semmelweis
University, Faculty of Medicine, Budapest. In 2011, he defended his PhD
dissertation entitled ‘Treatises on psychiatric disorders as risk factors of somatic
disorders and risk factors of suicide’. His research interest includes the
background mechanisms of mood-disorders-associated high risk of
cardiovascular disorders, suicide risk factors and various aspects of smoking in
patients with psychiatric disorders. He received the Research Prize of the
Association of European Psychiatrists twice in 2008 and 2011.
David Giannini is currently pursuing a doctoral research program in clinical
psychology at Palo Alto University, California. His research interests include
the experience of trauma, military psychology, suicide and substance abuse. He
is currently researching bravery and the links between military service and
suicidality.
Peter Goldblum, PhD, MPH, is a Professor of Psychology, Director of the
Center for LGBTQ Evidence-Based Applied Research (CLEAR), Director of
the LGBTQ Area of Emphasis, Co-Director of the Multicultural Suicide
 List of contributors xiii
Research Center, and Director of the Transgender Research Consortium at
Palo Alto University, California. He was a founder and original deputy director
of the UCSF AIDS Health Project and a visiting scholar and director of the
HIV Bereavement and Caregiver Study at Stanford. He is a pioneer in the
development of community-based mental health programmes for LGBTQ
clients, and has contributed to the professional literature related to gay men’s
health, AIDS-related suicide, end of life issues, HIV and work and AIDS
bereavement. He has co-authored two highly acclaimed books: Strategies for
Survival: A gay men’s health manual for the age of AIDS and Working with
AIDS Bereavement. In 2013, he received two awards from the American
Psychological Association for his work on LGBTQ issues in psychology.
Xenia Gonda, PhD, is a clinical psychologist and pharmacist currently work-
ing as Assistant Professor at the Department of Clinical and Theoretical
Mental Health at Semmelweis University, Budapest. She is also affiliated with
the Department of Pharmacodynamics at Semmelweis University, with the
Neuropsychopharmacology and Neurochemistry Research Group of the
Hungarian National Academy of Sciences and Semmelweis University, and
the Laboratory for Suicide Research and Prevention of the National Institute
of Psychiatry and Addictions. She is the recipient of the Bolyai Janos Research
Fellowship of The Hungarian Academy of Sciences. She is engaged in
full clinical work in addition to teaching at various universities and research.
Her main research fields include the genetic background of personality
and psychiatric illnesses, pharmacotherapy of bipolar disorders and biopsycho-
social approach to suicidal behaviour. She is the author of more than 100
scientific publications, primarily on the biopsychosocial and genetic aspects of
personality, mood disorders, and suicide.
Yari Gvion, PhD, is a supervising clinical psychologist who has worked for many
years in a psychiatric hospital and in private clinic and has 20 years’ experience
with patients who engaged in suicide attempts. She teaches in the Clinical
Division of the Psychology Departments at Bar-Ilan University and Tel
Aviv-Yaffo College. Her thesis examined the multi-dimensional effects of risk
factors for suicide attempts. Specifically she studies trait and state impulsivity
and aggression variables as distinguishing between different levels of attempts
severity.
Lori Holleran is currently a doctoral researcher in clinical psychology at Palo
Alto University, California. Her research interests include examining elements
influencing suicide and risk, implications of experiencing trauma, and dynamics
affecting criminal offending, as well as potential relationships between these
factors. Currently she is involved in research examining factors related to
predicting an individuals likelihood of experiencing chronic post traumatic
stress disorder (PTSD) at the National Center for PTSD. In the future
she is interested in integrating technology and treatment to offer more
comprehensive, accessible care to a broader group of individuals.
xiv List of contributors
Kasie Hummel is a doctoral researcher in clinical psychology at Palo Alto
University, California. She earned her MA in clinical psychology from
Minnesota State University in Mankato, MN, where her thesis focused on
geriatric psychology. Furthermore, she conducted research for a global health
disparities study focusing on sudden infant death syndrome (SIDS), stillbirth
and fetal alcohol syndrome (FAS). Currently, she is a member of the Clinical
Emergencies and Crises research group at Palo Alto University led by Bruce
Bongar. Her main research interests include military psychology, trauma and
correctional psychology.
Miriam Iosue is Lecturer of Psychology and Psychiatric Rehabilitation at the
University of Molise. She participated as investigator in studies assessing
impulsive and self-harm behaviours among inmates, as well as evaluating
genetic and neurobiological correlates of depression and suicide. She conducted
screening campaigns and programs aimed at raising adolescents’ awareness of
suicide and mental health within several European Union funded projects. She
is involved in the study of mental health problems and suicidal behaviour
among patients with obesity, diabetes and dermatological diseases. She is
member of the Section of Suicidology and Suicide Prevention of the European
Psychiatric Association and member of the International Association for
Suicide Prevention.
Hardeep Lal Joshi, PhD, is Assistant Professor, Department of Psychology,
Kurukshetra University, Kurukshetra. He has more than 15 years’ teaching as
well as research experience. He completed his specialized degree in Clinical
Psychology from the Institute of Human Behaviour and Allied Sciences
(IHBAS) which is affiliated to the University of Delhi. His specialization is in
the areas of clinical psychology, psychological testing, and mental health. He
has published twenty-five research papers in journals of national and
international repute.
Uri Kugel, MS, is a doctoral researcher in clinical psychology at Palo Alto
University, California. Uri earned his MS in clinical psychology from the
Leiden University in the Netherlands. He is a member of Clinical Emergencies
and Crises research group at Palo Alto University led by Bruce Bongar. His
main research interests include clinical emergencies and in particular suicide in
the US Military, within the US veteran population and suicide terrorism.
Additionally he conducts research in the field of evidence-based internet
assessment and clinical oriented artificial intelligence.
Carmel McAuliffe, PhD, currently divides her assignments between suicide
research with the National Suicide Research Foundation (NSRF) in Cork,
Ireland and as a cognitive-behavioural psychotherapist with St Patricks
University Hospital at the Dean Clinic in Cork. She previously worked as a
senior researcher with the National Suicide Research Foundation. In 2010 she
was awarded the Andrej Marusic prize for young suicide researchers. Prior to
this, she worked most of the time at the National Suicide Research Foundation
 List of contributors xv
and with the HSE Southern area in Cork. She has been involved in research
into suicide and deliberate self-harm over the last 17 years, with a special
interest in patients who engage in deliberate self-harm and the efficacy of
psychotherapy in preventing repeated suicidal behaviour as well as in
psychological autopsy studies and families bereaved by suicide. Since the mid-
1990s she has been involved in various international collaborative studies
including the WHO/Euro Multicentre Study on Suicidal Behaviour, the
Saving and Empowering Young Lives in Europe (SEYLE) project and
the Optimising Suicide Prevention Programs and their Implementation in
Europe (OSPI Europe) project. She has published in scientific peer reviewed
journals and contributed to international textbooks on suicidal behaviour.
Swati Mukherjee is Scientist ‘D’ at the Defence Institute of Psychological
Research (DIPR), Delhi. She is involved in many major research projects of
the Institute including suicide in the armed forces. She has written journal
articles and book chapters. She has been the associate editor of a volume on
Recent Developments in Psychology and has co-authored a manual on Suicide
and Fratricide: Dynamics and management for armed forces personnel and a
manual on Overcoming Obsolescence and Becoming Creative in the R&D
Environment for R&D organizations. Her areas of interest are social psychol-
ogy, positive mental health practices and suicidal behaviour. She was a recipient
of the Defence Research & Development Organization (DRDO) Best
Performance Award in 2008.
Emilie Olié, MD, is a psychiatrist in the Department of Psychiatric Emergencies
and Post-emergencies of the University Hospital and member of the INSERM
team ‘Vulnerability to suicidal behaviour’ in Montpellier, France. Her areas of
interest are suicidal behaviours, bipolar disorders and psychological pain. She
has expertise in functional neuroimaging. She has published scientific articles
in peer-reviewed journals and is the author of several book chapters dealing
with suicidal behaviours and pain. She coordinates the section for suicidal
behaviours study of the French Association of Biological Psychiatry.
Vijay Parkash, PhD, is Scientist ‘C’ at the Defence Institute of Psychological
Research (DIPR), Defence R&D Organization, Delhi. After completing his
post-graduate degree, he was awarded the DRDO Research Fellowship, and he
completed his doctorate degree in psychology from Kurukshetra University,
Kurukshetra. His interest areas are health psychology, personality and
psychometrics. He has ten years of research experience. He also served as a
psychologist on the Air Force Selection Board, Dehradun for two years. He has
been involved in many major research projects related to suicidal behaviour and
test constructions for personnel selection in the armed forces and paramilitary
forces. He has been an editor of three volumes – Recent Developments in
Psychology, Counseling: A practical approach and Positive Psychology: Applications
in work, health and well-being, and he has more than 15 other academic
publications in the form of journal articles and book chapters.
xvi List of contributors
Samantha Pflum, MS, is a fourth-year doctoral researcher in clinical psychology
at Palo Alto University, California. She is a member of the LGBTQ psychology
and child and family areas of emphasis. She is a lead student in Palo Alto
University’s Transgender Research Consortium, and is currently conducting
research related to social support and mental health outcomes in the
transgender population. She is a student editor and chapter co-author of a
forthcoming Oxford University Press book, The Challenge of Youth Suicide
and Bullying. Clinically, Samantha conducts individual, group and family
therapy in a community mental health clinic and an elementary school. She is
passionate about working with underserved populations, particularly sexual
and gender minorities. Samantha also serves as a teaching assistant, tutor
and adjunct adviser to fellow students. Her areas of professional interest
include suicidology research, as well as LGBTQ, child/paediatric and family
psychology.
Yury E. Razvodovsky, MD, PhD, is a psychiatrist specializing in social psychia-
try. He has worked as an associate professor at the Department of Psychiatry
in Grodno State Medical University, Belarus. Currently he is research scientist
at the Central Scientific Laboratory in Grodno State Medical University. He
has published more than 500 articles in English and Russian peer-reviewed
journals and conference papers focusing on epidemiology of suicides and
alcohol-related problems in transitional society. He is a founding member of
the International Society of Addiction Medicine (ISAM) and an active member
of the National Association of Psychiatrists.
Zoltán Rihmer is a professor of psychiatry at Semmelweis University, Budapest,
Hungary. His special interest is the clinical and biological/genetic aspects of
mood and anxiety disorders, with particular regard to the prediction of treat-
ment response and prediction and prevention of suicide. He has published
more than 440 scientific articles and book chapters and five books. He received
the Nyírő Gyula Award from the Hungarian Psychiatric Association 1987, the
Award of the Medicina Publishing House 1987 and 2012, the Brickell Suicide
Research Award of the Department of Child and Adolescent Psychiatry,
Columbia University, New York 1999, the Premio Aretaeus of the Associazione
per lo Studio della Malatia Maniaco-Depressiva 2010, the ‘Szabó György
Award’ of the Hemingway Foundation 2010, Lifetime Achievement Award of
the European Bipolar Forum 2011, the Lifetime Achievement Award of the
Hungarian Psychiatric Association 2012, the ‘Széchenyi Award’ of the
Government of Hungary 2012, and the Aristotle Gold Medal of Lifetime
Achievement in Mental Health given by the International Society of
Neurobiology and Psychopharmacology. He is a member of several Hungarian
and international scientific associations and boards.
Vsevolod A. Rozanov, MD, PhD, has an extensive background in the study of
suicidal behaviour, starting with educational training at the Karolinska Institute
to his current position as Professor and Chair of Clinical Psychology
 List of contributors xvii
at Odessa Mechnikov University and lecturer in the Suicide Research and
Prevention Centre. In 1997 he created a non-government non-profit
organization ‘Human Ecological Health’ that became contractor for several
educational, research and implementation projects in suicide prevention sup-
ported by different charities. In 1999 he started collaborating with Professor
Danuta Wasserman from Karolinska Institute, Stockholm, and in 2000 became
director of the Ukrainian part of the Swedish-Ukrainian genetic project on
suicidal behaviour. In 2000, he also started collaboration with the European
Network on Suicide Attempts Monitoring and Prevention (led by Wurzburg
University) and headed the corresponding Collaborating Centre in Odessa. In
2008 he established a collaborative Suicide Research and Prevention Centre
under the Odessa National Mechnikov University and Human Ecological
Health, developed curricula and established on-going education in suicide
prevention and mental health promotion for psychologists, GPs, school
teachers, military and other focus groups. He is the author and co-author of
more than 300 published articles, reviews, books for students and chapters in
international textbooks.
Marco Sarchiapone, psychiatrist and psychoanalyst, is a professor at the
University of Molise, Italy. He has been involved in research in the field of
suicidology for more than 20 years in an interdisciplinary perspective, ranging
from biological aspects to social and psychological correlates. He is
Vice President of IASP (the International Association of Suicide Prevention).
He is deputy co-ordinator of SEYLE (Saving and Empowering Young
Lives in Europe) and WE-STAY (Working in Europe to Stop Truancy
Among Youth) – two research projects regarding the prevention of suicidal
and other risk behaviours in adolescence, funded under the EU 7th
Framework Programme. He is also one of the promoters of SUPREME
(Suicide Prevention by Internet and Media Based Mental Health Promotion),
funded by the European Agency for Health and Consumers and a site leader
in the European project, MONSUE (Monitoring Suicide in Europe). In Italy,
he has been responsible for a large research project on psychological and
genetic factors associated with violence and self-harm behaviour in prisoners.
He was the President of the 13th European Symposium on Suicide and
Suicidal Behaviour.
Elvin Sheykhani is a doctoral researcher in clinical psychology at Palo Alto
University, California. His main research interests include crisis management
and military psychology. He is interested in working with the US veteran
population within the domain of suicide prevention within active duty and
reservist personnel. He conducts research on suicide prevention within the US
military and assessment of special operations personnel.
Joseph Tomlins is a doctoral researcher in clinical psychology at Palo Alto
University, California. His graduate work focuses on clinical emergencies such
as suicide. His current interests include military suicide risk assessment,
xviii List of contributors
intervention, treatment, and post-intervention practices. He has presented on
clinical emergencies at national conventions such as the American Psychological
Association (APA). Most recently, he presented a presidential symposium on
military suicide risk assessment at the 2013 APA convention. He also has two
years’ experience in clinical work. He has received specialized training in
LGBTQ issues at the Sexual and Gender Minorities Clinic in Los Alto, CA.
Kaitlin Venema, is a doctoral researcher in clinical psychology at Palo Alto
University, California. Her previous research at the University of Washington
includes the study of early biomarkers of autism spectrum disorders and
perceived tool use in infancy. At Palo Alto University, she is working under
Bruce Bongar examining suicidality in sexual minorities, military populations,
and terrorists. She is also involved in research exploring institutional review
boards (IRBs) practices surrounding suicide research, as well as bravery during
heroic acts. In terms of clinical work, she is interested in working with children,
adolescents, LGBTQ youth, families, and individuals with trauma histories.
Particularly, she is interested in preventative interventions for high-risk
populations in the community and interventions for bullying.
Paul S. F. Yip is the Director of the Centre for Suicide Research and Prevention
and a professor in the Department of Social Work and Social Administration,
The University of Hong Kong. He has served as a national representative of
the IASP since 2002 (Hong Kong Region) and a fellow of the International
Association of Suicide Research. He has research interests in population health
and suicide prevention areas. He has published papers in bio-medical-socio
areas. His recent monograph Suicide in Asia: Causes and prevention, published
by the Hong Kong University Press, has provided an important contribution
in understanding suicide and its prevention in Asia. He has served as an
honorary governor on the board of Suicide Prevention Service and a consultant
for Beijing and Shenzhen Suicide Prevention Service and for the Hong Kong
Government on population health issues. He received a Distinguished Alumni
Award from La Trobe University in 2008 for his excellent research and service
on population health. He is also a recipient of an Excellent Research Award
‘Charcoal Burning Suicide’ by the Health and Welfare Bureau of Hong Kong
SAR Government, 2007 and a Silver Asian Innovation Award, by Asian Wall
Street Journal and Singapore Economic Development Board, 2005.
Foreword

For those involved in suicide prevention and suicide research, every new contribution
to this field represents a further step forward in the dissemination of the principles
operating in such an area. However, among the hundreds of papers and books that
are published each year, not all try to shed a real light on the understanding and
prevention of suicidal behaviours. The book edited by Updesh Kumar, the suicidal
behaviour researcher and senior military psychology scientist in India, is the kind of
contribution that helps the reader gain a new insight into the suicidal phenomenon.
Nowadays, we are witnessing a new era in the research and prevention of sui-
cide. This enigmatic phenomenon has attracted the attention of many different
thinkers in centuries of human history, from philosophers to clergy, from doctors
to sociologists. Needless to say, that an integrated view of the phenomenon has
always been much needed. We have now a rare opportunity to discover the deli-
cate mechanisms that mediate genetics, environment and suicide risk, which were
not foreseeable even a few years ago. Furthermore, when dealing with suicide risk,
one needs proper assessment, regardless of family history, environment and past
trauma. This book guides the readers to reach a detailed understanding of suicidal
behaviour which is the key concept in suicide prevention, being assessment and
management of suicide features traceable in the same person.
My view as a dedicated suicidologist and psychiatrist is that my model for
depicting suicide refers to the two distinct dimensions that often overlap, the one
comprising psychiatric disorders and the other referring to suicidality. When
substantial overlapping exists, there is major risk of suicide as the patient is
‘attacked’ in two ways. However, suicide can occur with no psychiatric disorders
when profound distress and psychological pain become unbearable and when
suicide is seen as the perfect solution. In suicidal individuals, psychological pain
affects the very core of their human condition and threatens life, which cannot be
accepted in its present condition. It is this aspect that characterizes suicide deaths,
and it is absent in the vast majority of psychiatric patients. A psychiatric disorder
alone, therefore, is not sufficient to precipitate suicide. There must be the
suicidality dimension that carries some variant of negative emotions. I found this
book very helpful in providing a detailed analysis of the psychological pain.
Unbearable psychological pain has been labelled by my mentor and dear
friend Edwin Shneidman, ‘psychache’ which can be clearly distinguished from
xx Foreword
depression or other psychiatric disorders because of the uniqueness of suffering
perceived by the subject and because of the fact that the subject cannot stand it.
The individual cannot see a way out and believes that ending their life is the
solution. I considered psychache to be the main ingredient of suicide and if
tormented individuals could somehow stop consciousness and still live, they
would opt for that solution. Suicide occurs when the psychache is deemed by that
individual to be unbearable. It is an escape from intolerable suffering; and this
views suicide not as a movement towards death but rather as a remedy to escape
from intolerable emotion, unendurable or unacceptable anguish.
Having said that, there are, however, interventions that must be considered
beyond the single individual. These include interventions to change the attitudes
of the mass media when reporting suicide, which in turn may influence clusters
of suicide. Knowledge of genetics and the biology of suicide is also of paramount
importance to accomplish the new target of science, that is personalized medicine;
grouping together biological markers and the clinical picture. Moreover,
intervention through policies, for example, regulating alcohol consumption, has
proved to be very effective as well as other interventions that regulate access to
lethal methods, the integration of minority groups and getting to know the
medical consequences when dealing with suicide risk.
This book, with an extraordinary panel of contributors, contains a comprehensive
synthesis of the underlying dynamics of suicidal behaviour and is no doubt a must
read book for anyone involved in suicide prevention and those who want to
familiarize themselves with the phenomenon. This will serve as a beacon for
contemporary researchers in this field and is also a practical tool for stakeholders
and policy-makers.

Maurizio Pompili, MD, PhD

Professor of Suicidology,
Director, Suicide Prevention Centre,
Sapienza University of Rome,
Italy
Preface

Suicidal behaviour has been a matter of growing research interest among social
scientists and psychiatrists in the recent past as it is one of the major causes of
death across the globe. Suicide accounts for a life approximately every 40 seconds
and it is considered to be one of the three leading causes of death among young
people. The World Health Organization estimates that more than one million
people lose their lives every year by means of suicide and this figure is likely to
increase above 1.5 million per annum by 2020. Suicidal behaviour includes a
process that occurs in varied forms of varying degree of severity, starting from
ideation or thought level to completed suicide. On the one hand, it may be as
fatal as an act of killing oneself and, on the other, it can be the non-fatal behaviour
of a person just wishing him or herself dead that also constitutes suicidal behaviour.
Suicide is widely regarded as a personal act deeply rooted in the subjective will of
a person. Suicide is currently among the major public health problems in most
countries around the world and the seriousness and scope of this maladaptive
behaviour have projected a pressing need for a better understanding of the
situation from a multidimensional perspective and forced planning and
implementation of effective preventive strategies, as well as health care policies to
curb suicidal behaviour.
Although a growing number of social scientists and health care professionals
have recently been dedicating their efforts to research on various aspects of
suicidal behaviour, a relatively small and constrained body of existing literature on
the precipitating factors fundamental to suicidal behaviour reveals the relative
paucity of a comprehensive focus on the understanding of the specific origin,
roots and channels of occurrence of suicidal behaviours. The associated factors
and underlying dynamics behind varying trends of suicide have always remained
complex. To tackle suicide crisis from the core it is important to identify and
analyse these covert aspects. Addressing these calls, this volume Suicidal Behaviour:
Underlying dynamics tries to challenge the elements of randomness about suicidal
behaviour and describes how suicidal behaviour is modelled, both socially and
spatially. It is an attempt to minutely delineate the process in which all the
biological, psychological, sociological and even geographical factors contribute
significantly to the varying trends of suicide worldwide. The volume presents a
multifaceted approach to understanding the epidemiological side of suicidal
xxii Preface
behaviour, to appreciate and comprehensively portray the underlying dynamics in
a single resource and to open further avenues for researchers and academia to
expand and delve into the diversity of suicide research.
In order to systematically uncover the underlying dynamics of suicidal behaviour,
the volume bases its matter of discourse on sixteen chapters contributed by
internationally acclaimed scholars and experts in the field of suicidal behaviour, and
attempts to eliminate the existing gaps in the subject by reflecting upon the
phenomenon across different communities and countries. The text has been
divided into two parts. Part I is focused on elaborating the theoretical underpinnings
and comprises eight chapters on various psycho-sociocultural aspects of suicidal
behaviour. It begins with a conceptual arena on the subject matter, which primarily
concentrates on thorough understanding of the roots of a suicidal process, ranging
from genetics through personality to environment, and it further thoroughly
unfolds the relation of suicidality to aggression, emotion dysregulation and
psychological stress. Simultaneously, along with the theoretical comprehension of
the process, it also focuses on specific risk assessment and various theoretical
approaches to prevention and intervention particular to the kind of dynamics that
underlie any particular suicidal act. Part I begins with ‘Conceptualizing suicidal
behaviour’, from a broad perspective including various definitions, theories and
models to enumerate the entire domain of suicidality from different scientific
perspectives. In this crucial introductory chapter Hardeep Lal Joshi, Vijay Parkash
and Updesh Kumar have delved into suicide as a multidimensional phenomenon,
and put forth a detailed conceptual framework of suicidal behaviour. They have
attempted to delineate the wide latitude of suicidality and tried to elaborate the
conceptual underpinnings from varied interdisciplinary perspectives explaining the
vast domain of suicidal behaviours. Considering it essential to list effective
preventive strategies and intervention techniques, they briefly cite some concrete
ways that can be utilized to help suicidal people and save their lives.
Suicidal behaviour is a complex and multi-factorial phenomenon and epi-
demiological genetic studies suggest that the genes of the serotonergic system
are linked to suicidal vulnerability. Building on the conceptual framework in
Chapter 1 and bringing out the hereditary links, in Chapter 2 of the volume,
Sarchiapone and Iosue try to explicate the ‘Genetics of suicidal behavior’. The
authors demonstrate the familial transmission of suicide and the way in which it is
distinct from the familial transmission of psychiatric disorders associated with
suicidal behaviour. The authors very well exemplify a specific clinical phenotype of
suicidal behaviour related to attempted and completed suicides by elucidating
various adoption and twin studies. Citing the role of heredity, they emphasize that
vulnerability to suicidal behaviour may involve interactions between genetic
factors, acting via the transmission of personality traits and environmental factors.
The authors also describe various gene approach studies and suggest the role of
different genes coding in suicidal aberration. They indicate that the Genome Wide
Association studies and epigenetics have a significant potential to examine large
sets of gene polymorphisms and heritable changes and thus improve our
understanding of the association between gene expression and suicidal vulnerability.
 Preface xxiii
Ranging from the exploration of genetic factors to understanding of the
personality and temperamental make-up of an individual, probably social scien-
tists have delved deep into the roots of suicidal behaviour to understand the
pathways leading to its evolution and sustenance. The forthcoming chapters focus
on the linkage of various psychological constructs of personality, emotion dys-
regulation and impulsiveness with various types of suicidal behaviour. Describing
in Chapter 3, ‘Suicidality and personality: linking pathways’, Parkash and Kumar
delve into various personality factors linked to different aspects of suicidality.
Considering the widely accepted personality descriptive models including the big-
three and the big-five, they have attempted to highlight all the important paths
that link an individual’s personality make-up with various suicidal dimensions,
thereby making an individual vulnerable. The genetically determined side of
personality – temperament – has also been elaborated to reveal its precipitative
effects on suicidality. In the attempt to uncover all personality-related linking
pathways to suicidality, they have also tried to concisely explain various related
personality aberrations in the form of disorders and the way they form a bridge
to suicidal behaviour. The need to focus on very specific narrower personality
traits has been highlighted for a deeper understanding of the suicidal dynamics.
Covering the more specific and abstract personality aspects, in Chapter 4,
‘Emotion dysregulation and suicidality’, Anestis investigates the influence of
negative affect on vulnerability to suicidal ideation. The author has defined
emotion dysregulation as a multifaceted construct connected with problematic
outcomes of anti-social behaviour, non-suicidal self-injury and substance use.
Using the Interpersonal-Psychological Theory of suicidal behaviour, the author
differentiates between the desire for suicide and the capability for suicide and
states that most individuals with a suicidal desire will not have the capability and
those with the capability will not have the desire to commit suicide. Theories of
Dialectical Behaviour Therapy and Emotion Regulation Group therapy have been
regarded as effective psycho-social approaches to enhance an individual’s capacity
to regulate their emotions and teach distress tolerance skills. Taking the discourse
on personality-suicidality link further and deeper is the task of Chapter 5, ‘Role
of aggression and impulsivity in suicide attempts and in suicide completion’.
Gvion and Apter examine the influence of each construct independently as well
as in association and elaborate on how these contribute to various aspects of
suicidality. The authors amply cite that aggression has been linked to the act of
suicide in multiple epidemiologic, clinical, retrospective, prospective, and family
studies. They highlight that direct, proximate and indirect causal factors have
been studied while evaluating impulsivity within the context of suicidal behaviour.
While focusing on patients with disorders, the authors emphasize how impulsive-
aggressive personality disorders and alcohol abuse were two independent
predictors of suicide in major depression and aggression but impulsivity does not
appear to be a factor for patients with bipolar disorder.
Making the evidently perceived underlying dynamics explicit, in Chapter 6
Rozanov comprehensively describes the connections between psycho-social stress
and suicidal behaviour. In addition to the individual psychological factors, the
xxiv Preface
author here suggests various macro-, meso- and micro-level factors that mediate
the effect of social structure on individual and public health and has identified
excessive mortality, shortening of life expectancy, rise of life-threatening risky
behaviour and suicidality as major indicators of psycho-social stress. The
fluctuations in suicide rates in the European Union and the former USSR
countries have been aptly shown as supporting evidence to reflect the social and
economic processes and transformations taking place in the country. By classifying
the post-Soviet countries into two clusters – the one with high suicide rates and
marked rise of suicides in response to stress and the other with with low suicide
rates and blunted rise under the stress of transition – the author proves that
suicide rates vary in different cultures under similar stressful conditions but this
variation is not observed when mortality rates from cardiac infarction and
cerebrovascular diseases are examined. In addition, he also analyses gender
differences in suicide behaviour and other stress manifestations in these clusters.
The interconnection between stress and alcohol consumption has also been
reviewed and Rozanov proposes that national traditions and ethno-cultural
peculiarities play an important role in determining variations in suicidal behaviour
at the national level.
Revealing the suicide dynamics from another related point of view, in
Chapter 7 Courtet and Olié trace a pathway to suicide running from social
adversity to psychological pain and discuss the physiopathology of suicidal
behaviour in the light of psychological pain. They describe suicide as a major
social crisis in occidental countries and refer to the possible existence of an
association between economic crisis and suicide. Describing the isolated elderly
and prisoners as high risk populations, the authors attribute various social and
economic factors to the spatial and temporal variation in suicide. Psycho-social
stress, social vulnerability and social exclusion due to exposure to a harmful
environment, such as sexual abuse, emotional neglect, disturbed relationship with
parents or parental mental illness have been observed as carriers of negative
emotions of dread, grief, shame, guilt, etc. and key precursors of social and
psychological pain and thus, suicidal acts. Highlighting the need to avoid suicidal
mortality and suicidal thoughts, the authors propose the use of analgesic drugs
and also suggest prosocial pathways as protective factors for suicide.
The rise of modern communication systems, social networking and social
media has resulted in an increase of clustering and contagion of suicidal behav-
iour. Research in this area is still in its nascent stage and Arensman and McAuliffe,
in Chapter 8 of this volume, provide a review of the epidemiological, methodo-
logical, clinical and social issues in understanding the mechanism of suicide
clustering. In addition to geographical clusters, the significance of time and space
clustering among specific populations and settings, such as psychiatric inpatients,
adolescents and young adults in community settings has been well explored. The
authors worry about the recent rising trend of suicide clustering and contagion
in older adults which was earlier found mostly in adolescents and young adults.
Various approaches to assess clustering and contagion have been defined and the
authors emphasize the need to establish relevant public health, health and
 Preface xxv
bereavement support services for the needs of the people. The authors conclude
the chapter with a call for better crisis response training and highlight the need to
have a long-term programme of suicide risk reduction and community recovery.
Understanding suicidal behaviour remains incomplete without appreciating the
interplay of various causal factors that lead to suicide. The goal of reducing
suicides and suicidal behaviours can be accomplished only when the causes and
correlates of suicide are identified and addressed with precise adequacy. The rela-
tive scantiness of empirical attention paid to understanding suicidal risk has mostly
been the reason that has prevented clinicians and health scientists from achieving
this goal. Part II, ‘Varied research evidences and assessment perspectives’ focuses
on this very important aspect and brings to light the various precipitating factors
of suicide in diverse societies and cultures and the resources required to deal
effectively with suicide. This Part opens with Chapter 9 ‘Suicidal ideation and
behaviour among sexual minority youth: correlates, vulnerabilities, and protective
factors’, wherein Samantha Pflum and her associates have tried to explore the
relation of suicidal ideation among sexual minority youth by elucidating the men-
tal health disparities of LGBTQ (lesbian, gay, bisexual, transgender, queer) youth.
Depression, peer victimization and social isolation have been comprehensively
elaborated as some of the important correlates of self-harm. Being specific to the
correlative risk factors, the authors also provide recommendations for health prac-
titioners, family, and school administrators to maximize protective factors and
promote positive development and support.
Providing a detailed picturesque analysis of the global trends of various suicide-
related factors, the volume proceeds in the next few chapters to discuss suicidal
variations in different parts of the world including Hungary. In the tenth chapter,
Rihmer, Gonda and Dome attempt to provide a clearer impetus on understanding
the variations in suicidal behaviour by enunciating the spatial and temporal
distribution of suicidal behaviour with a special focus on Hungary. In addition to
psycho-social factors, genetic and biological contributions such as regional
differences and geographical factors are identified and well elaborated upon as
possible causes of the high suicide rates in Hungary. The authors report a positive
correlation between psychiatric disorders and suicide rate and examine the effect
of antidepressant treatments in reducing suicidal rates. To extend and illustrate
the variations in suicide in the next chapter, Clemans and Bryan conceptualize
suicide risk particularly for military personnel by deliberating on suicide in the
United States military. Risk factors between the civilian and military populations
are compared and the distinct culture of the United States military has been
considered as the discriminating and contributing factor. Further, Fluid
Vulnerability Theory has been adopted to conceptualize the risk of suicide among
service members and provide a theoretical foundation to assess the risk level of
military personnel. Illustrating the phases of the cognitive behavioural therapy
model, the authors have suggested specific intervention strategies to mitigate the
risk of suicide among service personnel.
Alcohol dependence ranks among the strongest suicide precursors and alcohol
addicts have higher rates of attempted and completed suicides. Though the
xxvi Preface
hypothetical relations are given consideration by the professionals, the origins of
the close relationship between alcoholism and suicide have rarely been investigated
and explored by researchers. Considering another global trend, Razvodovsky has
extended the issue on similar lines in Chapter 12, ‘Contribution of alcohol to
suicide mortality in Eastern Europe’ and he stresses that Eastern European
countries constitute the highest suicide rates. Attributing alcohol as the most
consistent predictor of suicide mortality and supporting his claim by highlighting
several studies and experiments, the author argues that alcohol is a strong
determinant of suicide both at the individual and population level. Drinking
patterns and culture are examined and credited as important indicators of the
alcohol–suicide association in spirits-drinking countries. Concluding his chapter,
the author lists various natural experiments and empirical evidence to evaluate the
efficacy of public health interventions and suggests that a restrictive alcohol policy
can be considered an effective measure of suicide prevention in such countries.
The reporting and portrayal of suicide in the media have a significant influence
on suicidal behaviour and the need for the proper depiction of media content and
a proper understanding of its influence on suicide contagion urge further research
in this area. Cheng and Yip delve in this emerging area of research in Chapter 13
and provide a critical review of media content representation of suicide in various
societies, wherein they demonstrate the ways that media representation differs in
various societies and the factors that influence these variations. Rather than focus-
ing on the quantitative representation of suicide issues, the authors critically
examine the content of non-fictional suicide reports in their study. They present
a systematic meta-analytic literature review process and propose that traditional
media representation possesses some common features but these are a result of
common patterns of media’s selective reporting that create myths in the readers’
mind. Certain communalities observed were in terms of suicide victims’ back-
ground, the method of suicide and the attributes leading to suicide. They also
report how celebrity and youth suicides using violent methods were more appeal-
ing to the media. On the other hand, the authors optimistically state that online
representation of suicide showed an inclination towards publishing anti-suicide
information. Revealing the global trends on this issue, they very aptly report a
cross-cultural study of suicide reports in Hungary, Japan, the United States,
Germany, Austria and Finland to comprehensively demonstrate the cultural vari-
ations of media representation in these countries. The authors emphasize the
importance of the implementation of media guidelines and the involvement of
professionals to steer the development of media representation towards prevent-
ing suicidal behaviour.
After discussing various factors contributing to suicidality, the scope of
the volume further extends to include the concept of suicide assessment and pre-
vention. Elaborating upon the formal assessment of suicide risk, Bruce Bongar
and colleagues in Chapter 14 examine the significance of formal risk assessment
in the mental health care system and describe a comprehensive psychological and
psychiatric evaluation based on the Risk Management Foundation of the Harvard
Medical Institution (RMFHMI). The authors summarize the clinician’s critical
 Preface xxvii
areas of exploration across the five domains of clinical diagnosis, history of suicidal
behaviours, client strengths and vulnerabilities, risk factors of self-harm, and pro-
tective factors. Based on these critical areas, the authors theorize that strong
religious beliefs, fear of social disapproval, a positive social support group, positive
coping abilities and a positive family structure would restrain individuals from
suicide attempts. The authors’ critical review of the formal assessment of suicide
risk in three distinct mental health care settings of Veterans’ Affair Hospitals,
general hospitals and community mental health gives a broad perspective to iden-
tify at-risk patients and suggests specific training protocols and step-by-step
evaluation measures not only to identify risk factors but also to educate health
professionals in the proper diagnosis of a suicidal individual. Maintaining the line
of significance assigned to suicide risk assessment but slightly shifting the focus to
the cultural identity of groups and individuals, Kugel and his associates in
Chapter 15 bring forward the aspects of suicide risk in culturally diverse popula-
tions in their chapter ‘Culturally competent suicide assessment’. The authors
describe how the various constructs of suicide such as suicidal ideation, suicide
method and risk and protective factors vary between ethnicities, gender and sex-
ual orientation and express a concern about the need to develop and validate
measures to recognize the unique factors to assess accurate risk levels across cul-
turally diverse populations. Furthermore, the authors explain the CARS (Cultural
Assessment of Risk for Suicide) measure based on the four categories of the
Cultural Model of Suicide – cultural sanctions, idioms of distress, minority stress
and social discord – to address the risk and cultural disparities in suicide among
four diverse cultural minority populations of Asian Americans, Latino/a
Americans, African Americans, and sexual minorities.
As the volume moves towards the end, it is important to discuss the best
practices that must be undertaken in dealing with suicidal behaviour. In the last
chapter of the volume, ‘Ethical and legal issues in dealing with suicidal behaviour’,
Mukherjee and Kumar provide an overview of the prevalent dilemmas and the
ethical and legal considerations in the process of suicide assessment and suicide
prevention. Describing ethics as aspirational standards a counsellor should strive
to attain, the authors highlight the moral dilemma involved in accepting the act
of suicide as rational or irrational. The authors elaborate upon the general
principles for constituting ethical standards in counselling. Beneficence and non-
maleficience, fidelity and responsibility, integrity, justice and respect for people’s
rights and dignity have been listed as the important principles that are crucial for
building a healthy client–counsellor relationship. The authors provide a legal
perspective to the issue by delving into the case of India in particular. The chapter
concludes by underlining the need for a legal and ethical framework and proposes
professional guidelines for understanding the client and creating an environment
for the healthy existence of humanity.
The theoretical underpinnings revealed in the first part along with a thorough
understanding of the causal factors and assessment procedures elaborated in the
second part of the volume present a comprehensive coverage of suicide-related
issues and widen the horizon of the readers to think beyond the epidemiological
xxviii Preface
perspective. The varied dynamics explored from a multidimensional viewpoint
give a panoptic description of the problem and variants of suicidality. The focus
on evolution, assessment and prevention of suicidal behaviour in a cross-cultural
milieu presented in this volume is an attempt to provide scope for researchers and
professionals working in this area across the globe to fully delve into each aspect
and cater to each community separately so that the stigma of suicide can be
effectively controlled and arrested.
Editing a volume on such a vast area of research is undoubtedly an arduous task
and I express my gratitude to one and all who contributed to the extensive work
and provided constant support. I am deeply indebted to the authors for the
time and effort they have given to the project. Their outstanding work significantly
contributed to a quality, informative and a professional product. I also wish to
acknowledge with thanks the kindness of my colleagues at the Defence Institute
of Psychological Research, Defence Research and Development Organisation,
New Delhi, for their patience and cooperation in successfully completing the
volume on suicidal behaviour in a short span of time. I hope this volume will serve
as a pivotal reference point for the health care professionals and research scientists
and will generate new ideas of research for the continual advancement of studies
on suicidal behaviour in the service of mankind.
Part I

Theoretical
underpinnings
This page intentionally left blank
1 Conceptualizing suicidal
behaviour
Understanding and prevention
Hardeep Lal Joshi, Vijay Parkash
and Updesh Kumar

Suicide is one of the major causes of death among people in the West and now
the suicidal cases are rising in the Eastern countries as well (World Health
Organization (WHO), 2012). WHO (1999) has estimated that approximately
1.53 million people will die from suicide, and ten to twenty times more people
will attempt suicide across the world by the year 2020. These estimates indicate
that on average one death will occur every 20 seconds and one attempt will be
carried out every one to two seconds. Although of low predictive value, in these
estimates the presence of psychopathology is perhaps the single most important
predictor of suicide (Gvion and Apter, 2012).
According to another WHO estimate, every year about 170,000 deaths by
suicide occur in India (as cited by Patel et al., 2012). As per a decade-old estimate,
every year, of the half million people dying by suicide across the world, 20 per
cent were Indians (Singh and Singh, 2003) of the 17 per cent of the world
population. In the past two decades the suicide rate has escalated from below 8
to above 10 per 100,000 (Vijayakumar, 2007). In a recent study published in the
Lancet in June 2012, it was estimated that about 187,000 suicides occurred in
2010 (Patel et al., 2012). These estimates show that suicide is fast becoming a
menace to human life and therefore it calls for urgent action that can lead to
finding ways to curb this growing tendency among people.
The aftermaths of suicide are often massive because not only does it
annihilate a person’s existence but also leaves his family and friends in the lurch,
thrusting upon them emotional, mental and physical stress. A person who
attempts suicide, essentially, needs medical help and treatment and therefore it is
necessary to broaden the knowledge regarding suicide and carry out extensive
research in this field.

Ancient understanding
Strikingly, in ancient times, the act of suicide was not considered dis-
agreeable and was instead regarded as a good method to avoid life’s frustrating
circumstances. Ancient Romans before the fourth century deemed
the quality of life to be of greater value than its longevity. Seneca, the first-
century Roman philosopher, acknowledged suicide as a decent way to end life’s
4 Hardeep Lal Joshi et al.
misery. Even the Christian Church began denouncing suicide as sinful only in
the fourth century which then proclaimed that the act of suicide is in violation
of the Sixth Commandment – Thou shalt not kill – and therefore began viewing
it as a crime. Later on, the Italian philosopher St Thomas Aquinas, in the
thirteenth century, declared that suicide is a mortal sin because it invades God’s
power over human life. Since suicide began to be considered a crime against God,
in Christianity, for a long time people committing suicide were debarred from
burial in a Christian graveyard. It is interesting to note that suicide continued to
be a criminal offence in the United Kingdom until 1961, where Christianity is the
major religion.
Like the European countries, the concept of suicide was grappled with
by Asian countries as well. From 1200 to the 1600s, suicide – hara-kiri in Japanese
– was viewed as a dignified means of departing from life’s disgraceful state of
affairs. In ancient India too, suicide was preferred as a better option to death from
disease. Considering the Confucianist views, the act of suicide is not condemna-
ble. In Confucian opinion, the act of suicide is seen in relation to the events that
lead up to it, and can therefore, depending on the circumstances, be seen as
something honourable or dishonourable. In China, where Confucianism is fol-
lowed widely, suicide is also seen as a passionate protection of one’s honour or
integrity and as a spirited resistance against something bad. In Confucian cultural
tradition, suicide in general is seen as something negative but it can sometimes be
justified if it is for a noble purpose. ‘Confucius would see suicide as an option for
protecting one’s virtue and integrity, but that more can be gained by doing well
in life instead of killing oneself’ (Van Tuan, 2010, p. 5).
From the Buddhist point of view, it is a common belief that life is a transitory
abode while death would be a long-lasting subsistence. However, in Buddhism,
it is believed that the next life depends on the way one lives one’s present life and
suicide is condemned because running away from this life by means of ‘death’
cannot prevent the anxieties of the next life. It shows that Buddhist beliefs are
close to the existential model of thinking (Van Tuan, 2010, p. 5). Similarly in
Islamic countries, suicide is regarded as an unholy act because the Quran, the
religious text of Islam, considers it to be one of the most horrible sins that
obstructs man’s spiritual path. This is one of the reasons why in most Muslim
countries suicide is still considered as a crime. Although some countries do
consider suicide a crime, individual suicide has been decriminalized in the Western
world. In the United States of America, it is not illegal to commit suicide but the
person can be penalized for an attempt. It is interesting to note that at present,
no European country considers attempted suicide a crime (McLaughlin, 2007),
whereas, in India, attempted suicide is a punishable offence.

Conceptualizing suicide
Many psychologists regard suicidal ideation as a form of mental illness and suicide
as an outcome of this illness and, therefore, an extensive body of work has
been done to study the various aspects and dimensions of suicide and suicidal
 Conceptualizing suicidal behaviour 5
behaviour. Sigmund Freud (1917) in his essay, ‘Mourning and Melancholy’,
postulated that the life-instinct ‘Eros’ and the death-instinct ‘Thanatos’ are the
two instincts that drive individuals. Researchers believe that Freud’s conceptuali-
zation of the

‘death instinct behaviors reflecting self-destructive tendencies, guilt

feelings, suicide, melancholia, masochism and sadism are furnished with a
motivational force of their own, as well as with a specific mechanism of action,
that is the repetition compulsion. The death instinct drives man to the
ultimate state of quiescence – death through the urge inherent in organic life
to restore an earlier state of things’
(Orbach, 2007, pp. 266, 267)

Freud used to believe that these self-destructive processes lead to depression and
suicide. He further posited that most individuals struggle between the two
instincts and suicide results when Thanatos wins over Eros. Although there have
been many scholars who have contributed enormously to the field of suicidal
behaviour research, major work in the conception of suicide was carried out by
American psychologist Edwin S. Shneidman in the 1950s. Around six decades
ago he co-founded the Los Angeles Suicide Prevention Center in 1958, for the
better understanding of suicide. Shneidman neologized various terms like
psychache, suicidology, psychological autopsy and postvention. As Shneidman
pioneered the research in this field he is often referred to as the father of
contemporary suicidology (Leenaars, 2010; Shneidman, 1993).
Derived from the Latin words ‘sui’ (of oneself) and ‘caedere’ (to kill) the word
‘suicide’ was first used in the seventeenth century by Sir Thomas Browne. He
introduced this term in his published book Religio Medici in 1643. In 1903 the
first ‘International Classification of Diseases and Causes of Death’ was adopted
which included ‘suicide’ in the section related to morbidity and mortality due to
external factors. Thinkers like Emile Durkheim and Sigmund Freud in their
respective studies pointed out the effect of external factors on suicide and there-
fore led to the encompassing of sociological and psychological aspects in the
definition of suicide. But before proceeding to the discussion of the definition
of suicide, it is essential to understand that the term ‘suicide’ is often used
only for those reported cases where the attempt to kill oneself has resulted in
death which apparently makes it quite a restricted term in the sense that it
does not cover all the other related aspects of the act. This often leads to flawed
estimation of the cases. Therefore, the term ‘suicidal behaviour’ is used to refer
to the multidimensional nature of suicide and the acts related to it. Though the
nomenclature of suicidal behaviours too has been an issue of international debate
among experts as well as there being variations involved in those cases where the
attempts do not lead to lethal outcomes, the term ‘suicidal behaviour’ is generally
used as a more inclusive term (Silverman et al., 2007a, b; Van Orden et al., 2010).
We all know readily what suicide means whenever it is mentioned in
everyday life. But technically, the word suicide does not simply mean ‘killing
6 Hardeep Lal Joshi et al.
oneself ’. It is a much more complex concept and as mentioned above, the
complexity arises from the fact that suicidal behaviour is used to describe a
varied gamut of results, one of them being suicide. Basically, three categories of
suicidal behaviour have been suggested: completed suicide, suicide attempt,
and suicidal ideas (Beck et al., 1972).
It may be noted that not every act of killing oneself can be classed as
suicide. In order to be so, it is essential that the person must intentionally initiate
the act, in the full knowledge or anticipation of its lethal results. On the other
hand, there is much variation among the terms used for suicidal behaviours
without lethal results so those acts of terminating one’s own life which have
non-fatal results are designated as suicidality, attempted suicide, suicide attempts,
act of intentional self-harm or para-suicide (WHO, 1998). The International
Classification of Diseases, (ICD-10; WHO, 1992) too has created a separate class
of ‘Intentional Self Harm’ stating that it comprises ‘purposely self inflicted
poisoning or injury suicide (attempted)’ (p. 1013).
Researchers have contended that there is a continuum from suicidal
ideation to gesture to attempt to complete which depicts suicidal behaviour
(Crosby et al., 1999; Garland and Zigler, 1993; Silverman and Maris, 1995).
Suicidal behaviour generally begins with ideation which includes thoughts
about desire and method to commit suicide (Beck et al., 1988). The person here
thinks of or wishes to die, this then is reflected in his or her gestures, further
transmuting into an attempt and finally might be resulting into completion.
Hence it can be said that ‘suicidal behavior is a set of noncontinuous and hetero-
geneous spectra of behaviors, such that suicidal ideation, suicidal threats,
gestures, self-cutting, low lethal suicide attempts, interrupted suicide attempts,
near-fatal suicide attempts, and actual suicide’ (Bursztein and Apter, 2009, as
cited by Amitai and Apter, 2012, p. 986). Giving a nomenclature to major
suicide-related behaviours, O’Carroll et al. (1996) described suicidal ideation as
‘any self-reported thoughts of engaging in suicide-related behavior’; non-suicidal
self-injury as ‘direct, deliberate destruction of body tissue without lethal inten-
tion’; and a suicide attempt as a ‘potentially self-injurious behavior with a
non-fatal outcome, for which there is evidence (explicit or implicit) that the
person intended at some level to kill himself/herself’ (cited by Amitai and Apter,
2012, p. 986). These behaviours differ on the scale of rescuability and lethality.
In fact, rescuability and fatality are the factors that actually distinguish between
suicidal gestures and attempts. Rescuability is high and fatality is low in suicidal
gestures or parasuicide where the person concerned does not actually intend to
die yet he/she commits the act of self-directed violence. In the absence of
the intention to die as in the present context, the term ‘self-harm’ is used.
But when there is a presence of intent to die, the rescuability is low and the
chances of fatality become high. It may be noted that the applicability of the
conceptualization of suicidal behaviour on a continuum for every individual is
still to be proved (Silverman and Maris, 1995).
The attributes of lethal suicidal behaviour or suicide are quite different from
non-lethal suicidal behaviour. Shneidman (1985) theorized that suicide resulted
 Conceptualizing suicidal behaviour 7
due to an intense emotional and psychological pain called ‘psychache’, which
ultimately becomes unbearable and cannot be abated by previously successful
coping patterns. Suicidal death thus, in a sense, is an escape from this pain. This
notion of escape from unbearable experiences has also been endorsed by
another researcher, Baumeister (1990). He regards the act of suicide
as an escape from self, or at least self-awareness. An individual attains a state of
‘cognitive deconstruction’ in this attempt which involves both irrationality and
disinhibition, such that drastic action becomes logical. Some other researchers
have asserted that in most cases suicide is associated with negative events which
lead to a sense of meaninglessness of life and hopelessness about future (Beck
et al., 1985; Eyman and Eyman, 1992), which create, independently or in
combination, a psychological state that perceives suicide as a promising way
out. Still other researchers proposed that hopelessness about the future may
be a better long-term predictor of suicide (say, one or two years later) than it is
for the short term (weeks or months) (Clark, 1995).

Defining suicide
Over the years, several pioneers and researchers have defined suicide in their
own way, however, there still remains a need to have a single globally accepted
definition. Although there seems to be an inherent communality among
different definitions, some of the popular but differing definitions of suicide are
as follows:

• ‘All cases of death resulting directly or indirectly from a positive or

negative act of the victim himself, which he knows will produce this result’
(Durkheim, 1897/1951, p. 44).
• ‘All behaviour that seeks and finds the solution to an existential problem by
making an attempt on the life of the subject’ (Baechler, 1979, p. 11).
• ‘Suicide is a conscious act of self-induced annihilation, best understood
as a multidimensional malaise in a needful individual who defines an issue
for which suicide is perceived as the best solution’ (Shneidman, 1985,
p. 203).
• ‘Suicide is an act with a fatal outcome which the deceased, knowing or
expecting a fatal outcome had initiated and carried out with the purpose
of provoking the changes he desired’ (WHO, 1986).
• ‘A fatal willful self-inflicted life-threatening act without apparent desire;
implicit are two basic components lethality and intent’ (Davis, 1988, p. 38,
as cited by Maris et al., 2000, p. 30).
• ‘Death arising from an act inflicted upon oneself with the intention to kill
oneself’ (Rosenberg et al., 1988, as cited by Maris et al., 2000, p. 30).
• ‘The definition of suicide has four elements: (1) a suicide has taken place if
death occurs; (2) it must be of one’s own doing; (3) the agency of suicide
can be active or passive; (4) it implies intentionally ending one’s own life’
(Mayo, 1992, pp. 92, 95).
8 Hardeep Lal Joshi et al.
The above-cited definitions make it obvious that there is a lack of overall
agreement among researchers on which key aspects to be included in the
definition of suicide. Despite much debate, the researchers have still not
reached consensus about it but over time, certain common elements have emerged
from these different definitions. These elements include: the result of the
behaviour, the intent to die to attain a different status, the agency of the act,
the consciousness of results, the effect of a theoretical orientation and
the influences of culture. The WHO Working Group thus later adopted a
standard definition of suicide which not only includes all the above-stated
elements but is also theoretically neutral, free of value judgement and one that is
culturally normative. WHO (1998) defined suicide as the ‘act of killing oneself,
deliberately initiated and performed by the person concerned, in the full
knowledge or expectation of its fatal outcome’.
Apparently, in any definition of suicide the intent to die is the central
element. However, it may be noted that it is hard to be absolutely certain of the
thought pattern of the deceased unless he has made his intention to die clear by
way of a suicide-note or diary or a prior conversation. Then there are many
attempts made impulsively during brief critical circumstances and are thus hardly
planned. Besides, there are cases where people who think of committing suicide
often have an ambivalent attitude towards killing themselves. In all such cases
establishing a correlation between intent and outcome can be quite challenging
(Carson et al., 2004; WHO, 2002). Therefore, a slightly modified version of the
above definition has recently been proposed to make it even more comprehensive
and universally acceptable.

Suicide is an act with fatal outcome, which the deceased, knowing or

expecting a potentially fatal outcome, has initiated and carried out with the
purpose of bringing about wanted changes.
(De Leo et al., 2006, p. 5)

Suicide is a multifaceted phenomenon and it often occurs as a result of mutual

or reciprocal actions of various factors. Although many extensive studies
have been made in this field, there are still some problems which remain unsolved
such as the standard definitions of different subtypes and phenotypes of
suicidal behaviour and associated factors like aggression and impulsivity
(Gvion and Apter, 2012). The psychologists, therefore, still have a number of
questions to answer.

Theoretical perspectives
Though suicide is considered a behaviour related to modern society, it is not
necessarily so. Great philosophers also described suicide in one way or
the other. At that time, no theory was proposed because of less interest in this
topic, yet almost all the great philosophers gave their opinion on suicide. In the
Classical Greek era, suicide was always viewed negatively. Pythagoras proposed
 Conceptualizing suicidal behaviour 9
that suicide leads to imbalance because it is unnatural. Plato and Socrates also
described suicide as wrong and against the state. Aristotle proposed punishment
for committing suicide, considering it negative for mankind. It was in Classical
Rome, that the opinion regarding suicide changed. In this era, suicide was not
considered negative, or wrong, rather it was seen as a way to find freedom from
problems. Around 1500, the writers and philosophers started changing their
views regarding suicide. The main insight into the topic was provided by the
French philosopher Rousseau who tried to free suicide from evil. According to
Rousseau, the individual should not be blamed for suicide, it is society, which is
compelling him to commit this act. David Hume described suicide apart from the
concept of sin. Later on Immanuel Kant preserved the earlier Stoic stance, calling
suicide unjust. Goethe presents the opposite view to Kant’s, calling for right to
death. In history, views regarding suicide are never unidimensional, some consider
it negative whereas others stand at the opposite pole and justify its rationality.
Theoretically, suicide and suicidal behaviour are a complex and multi-
dimensional phenomenon. It is difficult to study this topic because in order to
compose a general theory, very large samples are required and in the general
population, fewer suicide attempts and deaths are found. Second, people who
actually attempt suicide are excluded from clinical trials, and those who die
because of suicide are never available for assessment. Although research concerning
suicidal behaviour has been conducted in an atheoretical context, different
theoretical models have been proposed to describe it. Major approaches describing
suicidal behaviour include biological, psychological and sociological perspectives.

Biological theories
There is a fair amount of research evidence that biological factors play an impor-
tant role in suicide. It is found that the suicide rate is higher in monozygotic-twins
as compared to dizygotic twins. It is also found that the suicide rate is higher
among biological relatives of suicide attempters as compared to normal pro-
bounds. Biological theorists also proposed that suicidal behaviour results from the
presence of biologically-based diathesis. According to recent research (Mann,
2003; Van Pragg, 2001), the dysregulation of the serotonergic system in the
ventromedial prefrontal cortex leads to a higher suicidal risk. Considering the role
of biological factors along with other psychological and social factors, Kinderman
(2005) proposed the biopsychosocial model wherein he suggested that biological
factors, social factors and other environmental or life events lead to mental
health problems through their conjoint effects on mental psychological processes,
and these are the final common pathways to mental ill-health which may
ultimately lead to suicidal behaviour in many untreated cases.

Psychological perspectives
Various psychological interpretations of suicide have been proposed by psycholo-
gists. Freud (1917) was the front runner among those experts. Freud suggested
10 Hardeep Lal Joshi et al.
that suicide is motivated by unconscious intentions. According to Freud, the root
cause of suicide was the loss or rejection of a significant object. The suicide
attempter turns a death wish towards the person himself which has been directed
against someone else. Freud considered it a type of self-punishment. The suicidal
persons feel a sense of guilt and criticize themselves for each and everything
and start developing prohibition towards harshness. In this way, the suicidal per-
son is unable to organize his experiences in a coherent way which ultimately
results in suicide. Freud’s theory of instinctual self-destructive behaviour was
further elaborated upon by Menninger (1938). He explained the three primary
dynamics underlying suicidal behaviour. These dynamics included the wish
to kill (ego – aggression turned inward); the wish to be killed (superego – self-
aggression stemming from guilt), and the wish to die. Although the wish to kill
is expressed against oneself by means of suicidal acts, the inherent aggression in
that wish is intended for an ambivalently valued person. Menninger further pro-
poses that the wish to be killed stems from intense superego guilt for outlawed
sexual and aggressive unconscious id desires. He asserts that the wish to die rep-
resents the strength of the unconscious death instinct rather than representing a
conscious (ego) wish to kill or a superego self-punishment. The wish to die indi-
cates an id desire to revisit the prior birth tranquillity and it is manifested in non-
fatal self-destructive acts and in self-exposure to dangerous activities. Because of
the innate intensity of the death instinct, the wish to die is thus a form of playing
with death (Menninger, 1938, as cited by Orbach, 2007, p. 267).
The other perspective on suicidal behaviour is given by cognitive behaviour
psychologists. According to this perspective, depression is the main cause of
suicide in which hopelessness is the main factor. The suicidal person views himself,
the future and the environment as negative and this negative evaluation along
with some cognitive errors and distortion pushes him to suicidal ideation and
suicidal acts. The final outcome, that is, suicide is the result of cognition the
person has developed. According to some cognitive behavioural psychologists,
it is the cognitive schema, and according to some it is the irrational beliefs which
are crucial factors in the development of negativity which is the main cause of
suicide among suicidal people (Beck et al., 1985).
Learning psychologists explained suicide as a learned behaviour. According to
them, it is the forces of environment that shape the suicidal behaviour which is
reinforced by the environment. Some psychologists like Bandura (1977) explained
suicidal behaviour in terms of social learning. Suicide is committed by the person,
as he observed it in the environment. The social learning theory points out the
role of imitation, gives indirect insights about suicide contagion, and posits that
a number of environmental factors such as suggestion on television, stories in the
newspapers and observing others, that is, modelling may be some of the factors
related to suicide.
Other researchers working in this area provide different types of explanations.
Baumeister (1990) propounded ‘escape theory’ and explained suicidal behaviour
in terms of motivations to escape from aversive self-awareness. He described a
causal sequence of six primary steps or escapist events leading to suicidal behaviour.
 Conceptualizing suicidal behaviour 11
The causal chain begins with events that make a person feel they are falling
severely short of standards and/or expectations. The failure so perceived is
attributed internally to the self and it makes self-awareness painful. This painful
self-awareness of one’s own inadequacies results in the generation of negative
affect; and, consequently, a desire emerges to escape from that painful self-
awareness and the associated affect. In the efforts to escape an individual attempts
to achieve a state of cognitive deconstruction and the deconstructed state brings
irrationality and disinhibition, making drastic self-harmful steps appear acceptable.
It is at that point of time when suicide may be viewed as the ultimate step in the
effort to escape from self and the world (Baumeister, 1990).
Williams (1997, 2001) expanded on the escape theory of Baumeister (1990)
by putting forth the ‘cry of pain’ model to explain suicidal behaviour. Williams
and colleagues (Williams, 1997; Williams and Pollock, 2000) contended that
engaging in suicidal behaviour is not a cry for help, but it is a cry of pain due to
a situation that is trapping a defeated individual. They proposed that suicidal
behaviour emerges as a painful reaction to a situation involving defeat and where
no avenues to escape or rescue are to be found. When these three conditions are
unavoidably present in a situation, it activates the helplessness and hopelessness
mode of behaviour, which may lead to suicidal behaviour (Williams and Pollock,
2000). Williams and Pollock (2000) explain that rather than the defeat itself, it is
the state of entrapment in that situation that poses a danger for an individual to
be involved in suicidal behaviour, because the sense of entrapment blocks the
motivation to escape a situation in other ways than by ending one’s life.
A more recent theory propounded by Joiner and associates (Joiner, 2005;
Van Orden et al., 2010) is known as the ‘interpersonal theory’ of suicidal
behaviour and is based on thwarted belongingness, perceived burdensomeness,
and acquired capability to withstand fear of death and perform lethal self-injury.
This model asserts that an individual may have a desire to end his own life when
he feels disconnected from others and feels that he is a burden on his significant
others. This theory further states the acquisition of the ability to lethally injure
oneself is a preliminary requirement for an at-risk individual to attempt
or commit suicide; and without this lethal ability one would not be able to
attempt suicide.
Another more recent explanation of suicidal behaviour can be seen in
O’Connor’s (2011) ‘Integrated Motivational-Volitional (IMV) Model’ that con-
ceptualizes suicidal behaviour as being determined by a complex interaction of
proximal and distal factors grouped into three phases: the pre-motivational, the
motivational and the volitional phase. The pre-motivational phase includes back-
ground factors and triggering events; the motivation phase includes the genera-
tion of suicide ideation and intention formation; and the final volitional phase
includes behavioural enactment and suicide attempt. One’s intention to engage
in suicidal behaviour is the key proximal predictor of suicidal behaviour. Taking
Williams’ (2001) assertions as the basis, this model also posits that suicidal inten-
tion results primarily from feelings of entrapment, which are triggered by defeat/
humiliation appraisals. The IMV model describes some specific moderators that
12 Hardeep Lal Joshi et al.
explain the transition from defeat/humiliation to entrapment, from entrapment
to suicidal ideation/intent, and from suicidal ideation/intent to suicidal behav-
iour (Meissner, 2013).
There is another perspective to explain suicidal behaviour which looks
upon suicide not as a uni-dimensional phenomenon but as a multi-dimensional
one. This view gives consideration to the probability of mixed causal sequences as
explained by the different perspectives above. According to this view, the suicidal
person experiences unbearable psychological pain and finds no way to escape
from it. The situation is traumatic. The suicidal person thinks that death is the
only solution for all the problems and he is in a heightened state of disturbance
explained by rejection, harassment, hopelessness and helplessness. The internal
attitude of the person is ambivalent, showing acceptance and rejection at the same
time. Simultaneously, many conflicts occupy the brain. The cognitive state of the
person is restricted showing only one direction in thinking. Volitional motivational
forces make the person take the drastic step of attempting suicide, the lethality of
which is determined by the ability to self-harm and the intensity of the volitional
force and accordingly it may result in completed suicide.

The sociological perspective

The major sociological interpretation of the problem of suicide was made by
French sociologist, Emile Durkheim (1897/1951). He argued that suicide had
less to do with the individual’s own decisions and it was mainly the outcome of
the societal influence on a person. In an attempt to explain suicidal behaviour by
means of particular patterns of tensions between the individual and society,
Durkheim categorized four types of suicide – Egoistic, Altruistic, Anomic and
Fatalistic. Egoistic suicide is committed when a person has fewer ties with people.
These people feel alienated from others; they enjoy less social support which is
important for a person to function as a social being. Egoistic suicide is believed
to occur among those people who feel socially excluded, with poor social support
and lack of integration with society which results in sense of personal failure
and worthlessness (O’Connor and Sheehy, 2001). Sociologists explain that
fewer suicides take place among married people because of their ties with
family members. Altruistic suicide is opposite to egoistic suicide as it is found
among the individuals who are actually overly integrated into society. Durkheim
opined that altruistic suicide is committed because of societal demands. It
was described as a response to cultural expectation. Earlier in India, the Sati
pratha was practised, a custom in which the widow in India threw herself on her
dead husband’s funeral pyre.
Anomic suicide was explained as linked with societal regulation or deregulation
and it is initiated because of a sudden change in a person’s relation with society.
He explained anomie as a sense of disorientation which could show great
vulnerability for suicide. This occurs when the societal rules guiding the lives of
people do not remain appropriate and individuals become redundant. This leads
to instability and alienation and, in some cases, suicide. According to Durkheim’s
 Conceptualizing suicidal behaviour 13
opinion, the fatalistic suicide is considered to be prevalent in the case of excessive
societal regulation where people feel that they have lost all direction in life and
have no control over their own destiny (O’Connor and Sheehy, 2001). Although
this sociological framework is as applicable today as it was over a hundred
years ago, experts from other areas do not agree with Durkheim because the
people who undergo some problems because of the sudden change in life also
commit suicide. Also, Durkheim’s postulations found rare empirical support and
they fail to explain why a specific individual commits suicide.
Although the models proposed by a large group of researchers in this field have
been discussed, there exist many other models that attempt to explain the process
of suicidal behaviour in various ways but lack evidential support. However, the
fact that remains common to all models is their focus on reflecting the suicidal
process from initiation to attempt. The importance of understanding suicidal
behaviour from multiple viewpoints lies in the basis it formulates for taking
appropriate preventive measures so that human lives can be saved from such
unnatural endings.

Preventing suicides
The relatively stable rates of suicide and suicidal behaviour over time highlight
the need for greater attention to prevention and intervention efforts. Effective
suicide prevention requires a thorough understanding of the suicidal process,
which we have tried to present in the preceding sections. The extent to which we
understand the dynamics underlying suicidal behaviour will help us to better
identify the people at risk. Effective strategies for the prevention of suicidal behav-
iour should target eliminating the dynamics that perpetuate the engagement of
an individual in suicidal acts. It can be seen that restricting access to lethal means
and training health care professionals to identify and manage depression and sui-
cidal behaviour are likely to contribute somehow to reducing suicide rates.
Although effective prevention programmes do exist, the need for greater dis-
semination of information and the further development of prevention efforts is
underscored by the fact that many people engaging in suicidal behaviour do not
receive treatment of any kind (Nock et al., 2008).
With the overall increase in suicidal behaviour, the need for effective inter-
ventions cannot be overstated. Intervention, also known as secondary prevention,
refers to the healing and care of the suicidal crisis. Suicide is an event with bio-
logical (including biochemical), sociocultural, interpersonal, psychological,
neuro-psychological and personal philosophical or existential aspects. Since sui-
cide is not exclusively a medical problem, it does not always require a medical
professional to save a life; a layperson too can sometimes serve as a rescuer. Even
so, other professionals such as psychologists, psychiatrists, social workers, psychi-
atric nurses, can play a major role in suicide intervention (Leenaars et al., 1994).
The fundamental principle of crisis intervention programmes for suicide across
the world is the belief that suicidal action is generally the product of a temporary,
reversible, ambivalent state of mind (Stillion and McDowell, 1996). Suicidal
14 Hardeep Lal Joshi et al.
behaviour involves numerous possible risk factors and most of the interventions
originate from an understanding of such factors. There are several techniques for
suicide intervention that are briefly outlined henceforth.

Crisis intervention
The main focus of suicide prevention efforts is on crisis intervention. The chief
aim of crisis intervention is to help an individual deal with an immediate life crisis.
In the case of a suicide attempt, the first step is to provide emergency medical help
to the individual at a general hospital or in a clinical setting. When an individual
who is considering suicide is ready to talk about his problem at a suicide prevention
centre, it becomes easier to prevent an actual suicide attempt. At a crisis
intervention centre, the main goal is to assist such an individual to regain his
ability to cope with his immediate problems at the earliest. Emphasis is usually
laid on: (1) maintaining contact with the individual over a brief period of
time; (2) helping the individual understand that the acute distress is negatively
affecting his capacity to evaluate the circumstances correctly and to choose
from possible options; (3) helping the individual realize that other means of
dealing with the crisis are present and are better than committing suicide;
(4) taking a directive and supportive position; and (5) helping the individual
see that the current distress and emotional turmoil will not continue forever
(Carson et al., 2004).

Treatment of mental disorders

The majority of those who attempt suicide suffer from a treatable mental disorder
such as depression, schizophrenia, substance abuse, or borderline personality
disorder. Studies and clinical experience have shown that the early identification
and appropriate treatment of such disorders are an important technique to prevent
suicide. In this respect, educating health care professionals to diagnose and treat
mood disorder patients can help in lowering suicide rates among those who are
at high risk.

Behavioural approaches
Another tradition in suicide prevention is that which concentrates on the par-
ticular characteristics of suicidal people, rather than focusing on mental disorder.
Such an approach directly aims at the behaviour (Linehan, 1997). A variety of
interventions have been developed, based on this approach, some of which are
discussed below.

Behavioural interventions
Behavioural interventions involve a mental health worker conducting therapy
sessions with the patient, and discussing prior and present suicidal behaviour and
 Conceptualizing suicidal behaviour 15
suicidal ideation, and trying to ascertain associations with possibly underlying
causal factors (Linehan, 1997). A study was conducted by Salkovskis, Atha and
Storer (1990) on patients at high risk of multiple suicide attempts, who had been
admitted to an emergency ward because of taking an antidepressants overdose.
The patients were given either the standard treatment for suicide attempts or the
standard treatment along with a brief ‘problem-oriented’ intervention – a form
of short-term psychotherapy that centred on the problem which was found to be
bothering the patient most. The study found a significant advantage for those
receiving the intervention along with the standard treatment six months after
treatment, in terms of a reduction in their rates of repeated suicide attempts.
Another study conducted by Linehan, Heard and Armstrong (1993) investigated
the efficacy of dialectical behaviour therapy with those patients who exhibited
borderline personality disorders, multiple behavioural dysfunction, significant
mental disorders and a history of multiple suicide attempts. The findings revealed
a positive outcome during the first year among patients who had received the
therapy as compared to those who received standard treatment. In another study,
MacLeod and colleagues (MacLeod et al., 1998) showed the effectiveness of
manual-assisted cognitive behaviour therapy in achieving significant improvements
in suicidal patients with a history of attempting suicide and displaying a deficit in
positive future thinking.

Quick help interventions

Recently some new programmes have been developed to provide immediate
help to the individual who is showing any hint of suicidal behaviour. In this type
of intervention, the patient or client is given an opportunity to be in touch
with any medical or other professionals at a difficult time. The Green card
technique is one of them. In the Green card intervention, the clients are given a
card, carrying a direct and immediate access to a variety of options, such as an
on-call psychiatrist or hospitalization. It has been shown that the Green card is
beneficial for those considering suicide for the first time (Cotgrove et al.,
1995; Morgan et al., 1993). The Tele-Help/Tele-Check service for the elderly
operating in Italy is another intervention technique which is based on the tenet
of availability of help and easy access (De Leo et al., 1995). Tele-Help is an
alarm system that the client can activate to call for help. The Tele-Check service
keeps in touch with the clients and calls them twice a week to check on their
needs and provide emotional support. This intervention technique has been
also found to be quite effective by means of promoting faster help availability
(De Leo et al., 1995).

Relationship-based approaches
It is known that social relationships play an important role in determining the
vulnerability to suicide: the more social relationships a person has in his life, the
less he is vulnerable to suicide (Litman and Wold, 1976). Many interventions aim
16 Hardeep Lal Joshi et al.
to increase social relationships so as to lessen repeated suicidal behaviour as
bringing about an improvement in social ties is regarded as vital by the therapist.
Such interventions improve in social relationships, which in turn serves as avail-
able help for the person under crisis. A particular outreach method, known as
‘continuing relationship maintenance’ (CRM) has been found to be effective by
Litman and Wold (1976). This approach involves an active reaching out to the
patient by the counsellor who strives to keep a regular connection with him. The
improvements resulting from this method included reduced loneliness, more sat-
isfactory intimate relationships, less depression and greater confidence in using
community services. The efficacy of ‘task-centred casework’ – a problem-solving
method that lays stress on the collaboration between a patient and a social worker
over matters related to daily living was shown by Gibbons et al. (1978) and a
greater improvement in handling social problems was shown by the group that
received task-centred casework. In another study conducted by Hawton et al.
(1987), a significant proportion of the out-patient group who received counsel-
ling focused on relationship building showed improvements in social adjustment,
marital adjustment and relationships with their families.

Community-based efforts
It is observed that instead of treatment of suicide-related behaviour of the
individual, the emphasis should be on the whole community so that this menace
is prevented at a broader level rather than treated at a narrower level. Some
of the community-based interventions that may prove vital to help curb the
suicide problem may be as discussed in the following sections.

Suicide prevention centres

Apart from the intervention techniques discussed above, there is also specific
community mental health services for individuals who exhibit suicidal behaviour.
There are suicide prevention centres intended to serve as crisis centres that
offer instant help, often over the telephone, but programmes with face-
to-face counselling and outreach work are also used. In a study conducted
by Lester (1997), 14 studies that examined the effectiveness of suicide
prevention centres on suicide rates were reviewed. Seven out of these studies
offered some confirmation for a preventive effect of these centres.

School-based interventions
In an attempt to train school staff, community members and health care
providers to identify those at risk from suicide and refer them to appropriate
mental health services, various programmes have been designed. The training
varies from programme to programme, but in every case a strong link to local
mental health services is necessary. It may be noted that the importance of mental
health professionals cannot be undermined despite the training of school staff
 Conceptualizing suicidal behaviour 17
members, parents and others involved in school programmes. Yet, health care
facilities solely cannot fulfil all the demands of young people, and thus school-
based interventions play an important role in suicide prevention.

Multi-systemic approach
Multi-systemic therapy was initially designed for adolescents with conduct
disorder, but has been modified later for adolescents with severe mental health
problems, including attempted suicide (Henggeler et al., 2002). This therapy
involves assessment of the risk of suicide, followed by intensive family therapy to
improve family support along with individual skills training for adolescents
to assist them develop mood-regulation and social problem-solving skills, along
with intervention in the wider school and interagency network to lower stress
and improve support for the adolescent. The technique also involves regular,
frequent, home-based family and individual therapy sessions, with additional
sessions in the school or community settings, for over a period of three–six
months. It has been found that multisystemic therapy was considerably more suc-
cessful in lowering rates of attempted suicide at one-year follow-up as compared
to emergency hospitalization and treatment by a multidisciplinary psychiatric
team (Huey et al., 2004).

Societal approaches
Experts in social sciences are of the view that the concentration should not only
be on the individual but also on the social environment in which the problem
behaviour is occurring. They propose some changes in the environment so that
the undesired behaviour should not occur.

Restricting access to means

Restricting access to the means of suicide can play an important role in preventing
suicide. This was first shown in Australia by Oliver and Hetzel (1972), who found
that suicide rates lowered when access to sedatives – mainly barbiturates, which
are lethal in high doses – was restricted. Besides, there is also evidence of a
decline in suicide rates when access to other toxic substances such as pesticides is
restricted. Gas detoxification – the removal of carbon monoxide from domestic
gas and from car exhausts – has proved effective in decreasing the rates of suicide.
Soon after carbon monoxide was removed from domestic gas, suicides from poi-
soning with domestic gas began to decline in England (Kreitman, 1972) and
subsequently in many other countries (Lester, 1998). The link between the pre-
sence of handguns at home and suicide rates has also been observed (Carrington
and Moyer, 1994; Kellermann et al., 1992). There are numerous approaches
to lowering gun-injuries, by means of restricting access to them. These often
focus on legislation on sales and ownership of guns and on gun safety. Gun
safety measures include education and training, different practices of gun storage
18 Hardeep Lal Joshi et al.
(like separate storage of guns and ammunition, and keeping guns unloaded and
in locked places) and trigger-blocking devices. Restrictions on the ownership of
firearms have been linked with a decrease in their use for suicide in some countries
such as Canada, the United States and Australia (Carrington and Moyer, 1994;
Lester, 1998). Hence, societal measures may also help in adopting suicide
preventive measures.

Conclusion
Suicide is a behavioural and social problem which is affecting each and
every society. The clear understanding of the nature of the dynamics underlying
suicidal behaviour is of paramount importance when designing effective preven-
tive mechanisms. Suicide is a multidimensional phenomenon and different theo-
retical perspectives provide crucial insights to find the roots of the huge problem
of suicide. Undoubtedly suicide is a problem not only for the person who com-
mits it but also for the family, other relatives and the entire society. There is the
utmost requirement to put adequate preventive measures in place to deal with this
social menace. There is a need for continued dedicated research efforts to explore
further, and social scientists along with medical professionals need to work in col-
laboration to prevent and treat this menace.

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2 Genetics of suicidal behavior
Marco Sarchiapone and Miriam Iosue

Suicidal behavior represents one of the most complex human behaviors,

influenced by the action of several biological, psychological and social factors.
To try to explain this complexity, the stress–diathesis model was proposed,
suggesting that the vulnerability to suicide is determined by a variety of
predisposing (distal) risk factors on which stressful life events and other
potentiating (proximal) factors act as triggers (Mann et al., 1999; Mościcki,
1997). In this sense, the person’s genetic make-up constitutes one of the most
important predisposing factors contributing to the suicide vulnerability.
It is now well established that suicide clusters in families and that genetic
factors seem to play a role in 30 percent–50 percent of cases with suicidal behav-
ior (McGuffin et al., 2001; Roy et al., 1995). The inheritance of suicidal behavior
seems to be linked to two main components: the predisposition to psychiatric
disorders and the predisposition to impulsiveness–aggressiveness traits. However,
the presence of genetic risk factors does not imply a deterministic mechanism
since the inheritance of suicidal behavior is related to the interaction of multiple
genes and the influences of the environment.

Family, adoption and twin studies

The aim of family studies on suicidal behavior is to compare its rates in
the relatives of subjects who showed or did not show this behavior. It is now
well established that suicidal behavior aggregates within families and that
individuals with a family history of suicidal behavior are at increased risk of
both attempting and committing suicide when compared with individuals
without such a family history.
In 1982, Murphy and Wetzel collected the family history of suicidal behaviors
(suicide, attempted suicide, and suicide threats) of 127 patients hospitalized after
a suicide attempt. They found that 16 percent of patients with a diagnosis of
primary affective disorder had a family history of suicide and 17 percent had a
family history of suicide attempts (Murphy and Wetzel, 1982). In 1983, Roy
studied patients with a wide variety of diagnoses, such as schizophrenia, unipolar
and bipolar affective disorders, depressive neurosis, and personality disorders.
Almost half (48.6 percent) of the patients with a family history of suicide had
24 Marco Sarchiapone and Miriam Iosue
attempted suicide. Comparing these patients with patients without a family
history of suicide, Roy found that a family history of suicide significantly increased
the risk for suicide attempt (Roy, 1983). In the same year, Tsuang studied the risk
of suicide in the first-degree relatives of schizophrenic, manic-depressive and
depressive patients in comparison with relatives of surgical controls, finding an
almost eight time higher risk of suicide among relatives of psychiatric patients.
Moreover, relatives of psychiatric patients who had committed suicide, when
compared with the relatives of patients who didn’t, showed a four-fold higher risk
of suicide (Tsuang, 1983).
Egeland and Sussex (1985) ascertained suicides for a 100-year period (1880 to
1980) in the Amish community in Lancaster County, Pennsylvania, showing that
suicides cluster in pedigrees. Indeed, of the 26 people who had committed
suicide, 19 (73 percent) were clustered in four primary pedigrees, containing a
heavy loading for affective disorders and suicide. They concluded that this
clustering of suicides followed the distribution of affective disorders in the kinship,
thus suggesting the role of inheritance. However, they also found family pedigrees
with heavy loadings for affective disorders but without suicides suggesting that
their presence was not in itself a predictor for suicidal behavior.
Similar results were reported not only among psychiatric patients (Powell,
2000; Tsai et al., 2002), but also among adolescents and young people (Shafii
et al., 1985) and in the general population (Kim et al., 2005; Qin et al., 2002;
Qin, 2003; Runeson and Asberg, 2003). For example, Runeson and Asberg
(2003) found that the rate of suicide was twice as high in the families of suicide
victims than in the families of comparison subjects who died of other causes
and that, despite the strong connection between suicide and mental disorder, a
family history of suicide was a significant risk factor independent of severe mental
disorder.
All these findings demonstrated that a familial transmission of suicide exists and
that it is at least partly distinct from the familial transmission of psychiatric dis-
orders often associated with suicidal behavior. Moreover, as noted by Brent and
Mann (2005), these studies showed how suicide attempt and completion are
linked to the transmission of a unique clinical phenotype of suicidal behavior,
since the rate of suicide is elevated in the families of attempters, and the rate of
attempted suicide is elevated in the families of suicide completers.
Nevertheless, family studies can only prove that there is a familial aggregation
of suicidal behavior but they are not able to distinguish how much this transmis-
sion is due to genetic or environmental factors (Brent and Mann, 2005). Stronger
evidence of a genetic susceptibility to suicidal behavior came from adoption and
twin studies. Adoption studies are designed to evaluate genetic and environmental
influences on phenotype through the study of first-degree relatives reared in dif-
ferent families and environments. One of the first studies was performed in
Denmark by Schulsinger et al. (1979) using the Danish adoption registry. They
compared the rates of suicide among the biological and adoptive relatives of
57 adoptees who committed suicide and among the biological and adoptive
relatives of 57 matched living adoptees. They found a six-fold higher rate
 Genetics of suicidal behavior 25
of suicidal behavior in the biological relatives of adoptees who committed
suicide. Moreover, none of the adoptive relatives of both suicide and control
cases committed suicide. Since 50 percent of the biological relatives of suicide
subjects had never had contact with psychiatric services, it was possible to suppose
that they did not suffer any psychiatric disorder thus confirming that suicidal
behavior is at least partially independent of the presence of psychiatric disorders.
Using the same adoption registry, Wender et al. (1986) compared biological and
adoptive relatives of adult adoptees with and without mood disorder. The bio-
logical relatives of the adoptees with mood disorder showed a 15-fold increase of
suicide, and this was particularly true for adoptees with a diagnosis of ‘affective
reaction’ which includes the inability to control impulsive behavior.
Twin studies compare the similarity of monozygotic (MZ) and dizygotic (DZ)
twins. Monozygotic twins share the same genes, instead dizygotic twins share
only 50 percent of them, for this reason if the trait similarity of monozygotic twins
is significantly higher than the similarity of dizygotic twins, this indicates that
genes play an important role in this trait.
Several studies demonstrated that MZ twin pairs have significantly greater
concordance for suicidal behavior than DZ twin pairs (Kallmann and
Anastasio, 1947; Roy et al., 1991; Segal, 2009). Roy, Segal and Sarchiapone
(1995) investigated suicide attempts among 35 living co-twins whose twin had
committed suicide, finding that 10 of the 26 living MZ co-twins had themselves
attempted suicide, compared with 0 of the 9 living DZ co-twins (p < 0.04).
Statham et al. (1998) studied a very large sample of 5,995 Australian twins.
The concordance rates were higher for both suicidal thoughts and for serious
suicide attempts in the MZ twins than in the DZ twins. After controlling for
other risk factors for suicide, such as psychiatric disorder, traumatic events and
neuroticism, a history of suicide attempts or persistent thoughts in the respond-
ent’s co-twin remained a powerful predictor in MZ pairs (odds ratio = 3.9), but
was not consistently predictive in DZ pairs. The authors concluded that, overall,
genetic factors accounted for approximately 45 percent of the variance in suicidal
thoughts and behavior.
Even if adoption and twin studies demonstrate the existence of genetic risk
factors for suicidal behavior, there are several methodological limitations in these
approaches (Brent and Mann, 2005; Lester, 2002) and they are not able to
identify what these genetic factors are which are being transmitted.

Candidate gene approach studies

Given the strong association with depression, the main focus of genetic studies
on suicide was the serotonin system. Studies suggested a role of serotonin
in suicide. Indeed, a low cerebrospinal fluid (CSF) concentration of 5-
hydroxyindoleacetic acid (5-HLAA), which is the main metabolite of serotonin,
was associated with increased impulsiveness, impaired control of aggressive
behavior and suicide attempts (Asberg et al., 1976; Linnoila and Virkkunen,
1992; Virkkunen et al., 1995).
26 Marco Sarchiapone and Miriam Iosue
Tryptophan hydroxylase (TPH) studies
Tryptophan is an essential amino acid for serotonin synthesis and the tryptophan
hydroxylase (TPH) is the initial and rate-limiting enzyme in the biosynthesis of
serotonin. In humans there are two TPH isoenzymes encoded by two genes.
TPH1 was the first to be identified and it is located on the short arm of chromo-
some 11 (11p15.3—p14). The second (TPH2) is located on the long arm of
chromosome 12 (12q21.1). An association between suicidal behavior and TPH1
polymorphism was first reported by Nielsen (1994), investigating 56 impulsive
and 14 non-impulsive, alcoholic, violent offenders and 20 healthy volunteers.
They found a significant association between TPH genotype and CSF 5-HIAA
concentration in the extreme impulsive group. In particular, the impulsive alco-
holics with the LL or UL genotype showed the lowest CSF 5-HIAA concentra-
tions. Since a history of suicide attempts was significantly associated with UL or
LL genotype in all of the alcoholic offenders, the presence of the L allele may
influence the predisposition to suicidal behavior. Most of the studies investigated
the TPH1 intron 7 A218C single nucleotide polymorphism (SNP) finding con-
flicting results. Bellivier et al. (1998) compared the TPH intron 7 A218C poly-
morphism in DNA samples from 152 bipolar disorder patients and 94 normal
controls. They found that the risk of bipolar disorder was increased by the pres-
ence of at least one copy of the TPH A allele, and the risk was higher for TPH
A–homozygous subjects. Nevertheless this TPH polymorphism was not associ-
ated with a history of suicide attempts. Lalovic and Turecki (2002) conducted a
meta-analysis on 17 publications concluding that the association between suicidal
behavior and an intron 7 polymorphism of the TPH1 gene was not demon-
strated. However, the studies on this polymorphism continued and more recent
meta-analyses confirmed its association with suicidal behavior (Li and He, 2006;
Rujescu et al., 2003). Galfalvy et al. (2009) published a perspective study of 343
patients with a Major Depressive Episode who were monitored for suicide
attempts for up to one year. The patients were genotyped for polymorphisms
A218C in intron 7 and A-6526G in the promoter region of TPH1. Both the AA
genotype on intron 7 and the AA genotype on the promoter predicted suicide
attempts during the one-year follow-up and were associated with past attempts at
high medical lethality. Baud et al. (2009) offered a possible explanation of the role
of TPH1 genotype in the predisposition to suicidal behavior. In their study, sui-
cide attempters carrying the AA genotype in intron 7 showed reduced capacity to
control anger, which is one of the most important risk factor for suicide ideation
and attempt.
After the identification of the second gene encoding for TPH (TPH2), the
focus of research shifted to this gene, especially because it is highly expressed in
the brain regions. Zill et al. (2004) reported an association of SNPs and a
haplotype with completed suicide, even if these findings were not confirmed by
De Luca et al. (2005) in schizophrenic patients. Recently, Fudalej et al. (2010)
showed a higher frequency of the TT genotype in the TPH2 SNP (rs1386483)
in suicide victims than controls, and this difference was particularly higher for
those with a history of repeated suicide attempts.
 Genetics of suicidal behavior 27
Serotonin transporter (5-HTT) studies
The serotonin transporter (5-HTT) regulates the serotonergic transmission,
since it is involved in the reuptake of serotonin from the synaptic gap. Mann
et al. (2000) collected postmortem brain samples from 220 individuals and
found that binding to 5-HTT was lower in the ventral prefrontal cortex of
suicides compared with nonsuicides. This alteration of 5-HTT binding in suicidal
individuals could be explained by differences in the 5-HTT gene. The most
studied is a polymorphism in the promoter region of the serotonin transporter
gene (5-HTTLPR) due to a 44 base pair deletion (SS)/insertion (LL) (Heils
et al., 2002). The homozygote (SS) and heterozygote (SL) short forms of the
5-HTTLPR locus are associated with fewer binding sites than in the long form
homozygote (LL). Bondy et al. (2000) compared Caucasian suicide victims and
healthy controls and reported a highly significant increased frequency of one or
two short alleles in suicide victims, independent of the clinical diagnosis. On the
contrary, Mann et al. (2000) reported that the 5-HTTLPR genotype was associ-
ated with major depression but not with suicide or 5-HTT binding. A meta-
analysis (Lin and Tsai, 2004) supported the association of the short allele
of 5-HTTLPR polymorphism especially with violent suicidal behavior in the
psychiatric population. Similarly, Wasserman et al. (2007) reported a higher
occurrence of the S allele among suicide attempters with a high medical damage.

5-HT receptors studies

A number of studies investigated the link between serotonin receptors and sui-
cidal behavior, finding conflicting results. A recent meta-analysis concerning
5-HTR1A concluded that the SNP C-1019G variant (rs6295) was not associated
with suicidal behavior (González-Castro et al., 2013). Similarly, a significant asso-
ciation between the HTR1B G861C polymorphism and suicidal behavior was not
confirmed (Kia-Keating et al., 2007). Turecki et al. (1999) demonstrated that
5-HTR2A binding was greater in the prefrontal cortex of suicide victims. They
also investigated two polymorphisms of the 5-HTR2A gene (T102C and
A-1438G) which significantly affected the receptor’s binding, even if no inter-
action between suicidal behavior and this locus was observed. Saiz and colleagues
(2008) compared suicide attempters and controls, reporting no differences
between the two groups in the genotype and allele distributions of two 5-HT2A
polymorphism, A-1438G (rs6311) and T102C (rs6313). Nevertheless, they
found an excess of the −1438A allele in nonimpulsive suicide attempts. Turecki
and colleagues (2003) investigated variation in genes that code for seven
serotonin receptors (5-HTR1B, 5-HTR1Da, 5-HTR1E, 5-HTR1F, 5-HTR2C,
5-HTR5A and 5-HTR6) and observed no differences in allelic or genotypic
distributions between suicide victims and controls.
The small sample sizes of the studies may have affected their power for
detection of genetic effects, moreover other 5-HT receptors were not sufficiently
investigated (Anguelova et al., 2003; Wasserman et al., 2009).
28 Marco Sarchiapone and Miriam Iosue
Monoamine oxidase (MAO) studies
Monoamine oxidases (MAO) are enzymes involved in the catabolism of amines
(serotonin, noradrenaline and dopamine). In humans there are two MAO
isoforms (MAO-A and MAO-B). The gene for MAO-A is located on the
X chromosome (Xp11.23) and the promoter of the gene contains a functional
polymorphism consisting of a 30-bp repeated sequence present in 3, 3.5, 4, or 5
copies. Alleles with 3.5 or 4 copies of the repeat sequence are transcribed 2–10
times more efficiently than those with 3 or 5 copies of the repeat (Sabol et al.,
1998). Genetic studies in mice linked deficiencies in MAO-A gene function to
increased aggression (Cases et al., 1995), which is an important risk factor for
suicide (Gvion and Apter, 2011; Linnoila and Virkkunen, 1992). Caspi (2002)
found that male maltreated children with a genotype conferring high levels of
MAO-A expression were less likely to develop antisocial problems in adulthood.
Prichard et al. (2008) did not find an association between the MAO-A genotype
and antisocial behavior, while Weder et al. (2009) reported a significant inter-
action between moderate levels of trauma exposure and the ‘low-activity’ MAOA
genotype in conferring risk for aggression. The literature concerning the associa-
tion of this polymorphism with suicidal behavior showed conflicting results.
Ho et al. (2000) reported that MAOA polymorphism was associated with history
of suicide attempts in bipolar subjects, especially females. Ono and colleagues
(2002) did not find evidence of association with completed suicides. Courtet
et al. (2005) did not confirm an association with suicide attempts, even if an
excess of high-activity MAO-A gene promoter alleles was associated with violent
methods of suicide attempt. A recent meta-analysis (Hung et al., 2012) concluded
that there is no association between the polymorphism and suicidal behaviors.

Catechol-O-methyltransferase (COMT) studies

The catechol-O-methyltransferase (COMT) is an enzyme involved in the
catecholamines’ inactivation. A functional polymorphism in the COMT
gene (COMT-V158M) was described as associated with lower enzymatic
activity (Weinshilboum et al., 1999). Rujescu et al. (2003) linked this polymor-
phism to suicidal behavior and anger-related traits. Ono et al. (2004) found
that the frequency of the Val/Val genotype, a high-activity COMT genotype,
was significantly less in suicide completers than in controls, but only in males.
Zalsman et al. (2008) excluded an association between the polymorphism and
suicidal behavior in mood disorder patients. A meta-analysis (Kia-Keating
et al., 2007) suggested an association between COMT and suicidal behavior
and highlighted possible gender differences. However, a further meta-analysis
(Tovilla-Zárate et al., 2011) did not confirm these results, suggesting that
additional studies are needed.

Neutrophins studies
Neurotrophins are a family of polypeptide growth factors, present in all
vertebrate species, which influence the proliferation, differentiation, and survival
 Genetics of suicidal behavior 29
of neuronal cells. The Brain Derived Neurotrophic Factor (BDNF) is a
neutrophin involved in neuronal and plasticity of serotonergic and dopaminergic
neurons. The BDNF gene lies on the reverse strand of chromosome 11p13 and
encodes a precursor peptide pro-BDNF. The tyrosine kinase B (TrkB) is the
BDNF receptor. Dwivedi et al. (2003) reported a significant reduction in the
mRNA levels of BDNF and TrkB in both the prefrontal cortex and hippocampus
of suicide subjects compared with nonpsychiatric healthy controls. Similar results
were described also for teenage suicide victims (Pandey et al., 2008). Karege
et al. (2005) reported a significant decrease in BDNF levels in the hippocampus
and PFC but not in the entorhinal cortex, of suicide victims, suggesting that a
decrease in BDNF may be specific only to certain brain areas.
A single nucleotide polymorphism in the BDNF gene, leading to a valine
(Val) to methionine (Met) substitution at codon 66 in the prodomain
(BDNFMet), was identified. Kim et al. (2008) showed a 4.9-fold higher risk of
suicide attempts in bipolar patients with the Met/Met genotype compared those
with the Val/Val genotype. We genotyped 170 depressed patients for the
BDNF Val66Met polymorphism (Sarchiapone et al., 2008), finding a significant
association between this polymorphism and suicidal behavior, even if a
further analysis on 512 subjects did not confirm this result (Zarrilli et al., 2009).
However, GXE and epigenetic studies provided additional evidence of the role of
BDNF in the pathogenesis of suicidal behavior.

Corticotropin-releasing hormone (CRH) studies

Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis seems to be
linked to suicidal behavior (Jokinen and Nordström, 2009). The HPA axis is
responsible for stress response and it is regulated by the corticotrophin-releasing
hormone (CRH). CRH is a hypothalamic factor that stimulates the pituitary
gland, binding two receptors, CRHR1 and CRHR2. Wasserman et al. (2008)
analyzed SNPs in the CRHR1 gene in 542 family trios with suicide attempter
offspring. They found a significant association of a SNP (rs4792887) with suicide
attempters exposed to low levels of stress, among whom most males were
depressed. They conducted a further investigation (Wasserman et al., 2009) and,
besides confirming previous results, they found other two risk SNPs (rs110402
and rs12936511) which were associated and linked with depression scores among
suicidal males. De Luca et al. (2007) analyzed three CRHR2 polymorphisms,
CRHR2(CA), CRHR2(GT), and CRHR2(GAT), in 312 families where at least
one subject had bipolar disorder. Even if there was no difference in the distribu-
tion of the alleles for all three markers, an association between haplotype 5–2–3
and higher severity of suicide-related traits was found.
In summary, the research on the CRH and HPA axis represents a new field of
interest in the genetics of suicide showing promising results.

Gene–environment interaction studies

A further step in our knowledge on genetics of suicidal behavior comes from
Gene–Environment interaction (GxE) studies. The most famous study in this
30 Marco Sarchiapone and Miriam Iosue
field was conducted by Caspi et al. (2003). They found that a genetic polymorphism
in the promoter of the serotonin transporter gene affects the likelihood of life
stresses precipitating depression. Moreover, the occurrence of stressful life events
predicted the onset of newly diagnosed depression or suicidal ideation and
attempts among subjects with the short promoter but not among subjects with
the long promoter. Roy et al. (2007) demonstrated how childhood trauma may
interact with low expressing 5-HTTLPR genotypes to increase the risk of suicidal
behavior among patients with substance dependence. Our studies on male
prisoners identified an interaction between childhood emotional abuse and the
AA 5-HT2A genotype in increasing suicidal risk (Sarchiapone and Vladmir,
2010). Brezo and colleagues (2009) performed a longitudinal cohort study
showing how HTR2A variants (rs6561333, rs7997012 and rs1885884) were
involved in suicide attempts through interactions with histories of sexual and
physical abuse.
Perroud et al. (2008) investigated the interaction between BDNF Val66Met
and childhood trauma in 615 non-violent and 198 violent suicide attempters.
They found that childhood sexual abuse was associated with violent suicide
attempts in adulthood only among Val/Val individuals. This interaction between
BDNF polymorphism and childhood trauma was not confirmed by the previous
cited study by Sarchiapone et al. (2008).
As described before, GxE effects were detected by Wasserman et al. (2008,
p. 1) in relation to the CRHR1 gene. They also described two other GxE effects
in suicide attempters: one among females, between 5´-SNP rs7209436 and
childhood/adolescence physical assault; the second, male-specific, between
3´-SNP rs16940665 and adulthood physical assault exposure. Roy et al. (2010)
investigated the FKBP5, an HPA-axis regulating gene, suggesting that child-
hood trauma and variants of the FKBP5 gene may interact to increase the risk
of attempting suicide.
These studies confirmed the genetic liability for suicidal behavior, which can
also be modulated by environmental factors as well as by psychological and
personality characteristics. Taking into account all these variables represents one
of the biggest challenges of future studies.

Future perspectives: genome-wide association

studies and epigenetics
Genome-wide association studies (GWAS) have demonstrated a great potential
for individuating new genes associated with suicidal behavior. The main advantage
of these studies is that they examine a large set of gene polymorphisms without
selecting one from an artificial hypothesis.
The first genome-wide scan of suicidal behavior was performed by Hesselbrock
et al. (2004). Significant evidence of linkage was found on chromosome 2 for the
phenotype suicide attempts. They also analyzed a ‘suicidality index’ related to
lifetime suicidal thoughts and behavior. This index showed modest evidence for
linkage to chromosomes 1 and 3, but these results did not reach statistical
 Genetics of suicidal behavior 31
significance. Willour et al. (2007) confirmed these results showing a covariate-
based linkage signal on 2p12 at marker D2S1777. Willour et al. (2011) extended
their analysis, finding an association signal on 2p25 (rs300774) at the threshold
of genome-wide significance. Perlis et al. (2010) analyzed data on lifetime
suicide attempts from genome-wide association studies of bipolar and major
depressive disorder providing suggestive evidences for different loci, while
Galfalvy et al. (2013) recently identified 58 SNPs. Nevertheless, how these
polymorphisms can be implicated in pathways leading to suicidal behavior
needs further clarification.
Epigenetics is often defined as the study of heritable changes in genome
function that occur without a change in DNA sequence. Sequeira et al. (2006)
identified a role for the SSAT342 locus in the regulation of gene expression of
SSAT, the rate-limiting enzyme in the catabolism of polyamines. Indeed they
found a higher frequency of the SSAT342C allele among suicide victims
compared to controls. McGowan et al. (2008) found a hypermethylation of the
rRNA throughout the promoter and 5´ regulatory region in the brain of
suicide subjects, consistent with reduced rRNA expression in the hippocampus.
Another study (McGowan et al., 2009) also reported decreased levels of
glucocorticoid receptor mRNA, as well as mRNA transcripts bearing the gluco-
corticoid receptor 1F splice variant and increased cytosine methylation of a
neuron-specific glucocorticoid receptor (NR3C1) promoter in the hippocampus
of suicide victims with a history of childhood abuse.
In the study conducted by Poulter et al. (2008), the DNA methyltransferase
(DNMT) gene transcript’s expression was altered in the frontopolar cortex, the
amygdala, and the paraventricular nucleus of the hypothalamus of suicide victims.
Furthermore, within the frontopolar cortex, three cytosine/guanosine sites in the
gamma-aminobutyric acid (GABA)(A) receptor alpha1 subunit promoter region
were hypermethylated relative to control subjects.
The already cited study by Dwivedi et al. (2003) reported a reduced expression
of BDNF and TrkB in postmortem brain in suicide subjects. We compared
44 suicide completers with 33 non-suicidal controls, describing a hyper-
methylation of BDNF promoter/exon IV in the Wernicke area of the
postmortem brain of suicide subjects. Ernst et al. (2009) showed a decreased
expression of TrkB.T1 in the frontal cortex (Brodmann areas 8 and 9) of suicide
completers and associated this downregulation with the methylation state
of the promoter region, while, in the same sample of the previous study, we
found that the TrkB and TrkB-T1 expression and promoter methylation in
Wernicke area did not correlate with suicidal behavior, confirming that the
expression and methylation state of suicide-related genes, even belonging to the
same pathway, may be specific for brain area.
The results of epigenetic studies are promising and are important to clarify the
mechanisms of DNA expression, improving our knowledge on the mutual links
that exist between life events, DNA sequence, gene expression and protein
synthesis.
32 Marco Sarchiapone and Miriam Iosue

Conclusion
All the discussed findings seem to confirm the important role of genetics in the
pathogenesis of suicidal behavior, also showing how the inheritance of suicide risk
factors is at least partially independent of the inheritance of psychiatric dis-
orders. As well as for other psychopathological traits, suicidal behavior inheritance
could result from the contribution of multiple genes with small effect size.
Nevertheless, genetics is only one of several factors which affect the suicidal
threshold and maybe only when specific combinations of genes meet specific
combinations of life events is suicide more likely to occur.

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3 Suicidality and personality
Linking pathways
Vijay Parkash and Updesh Kumar

The high incidence of suicidal deaths make it an issue of grave concern and a
potentially dangerous public health predicament as it is among the leading causes
of death among youths across the globe. Suicide is considered to account for over
one million deaths per year making it one of the ten leading causes of death
(Hawton and van Heeringen, 2009). Regardless of rigorous efforts, successful
prophecy and protective strategies have remained obscure; and it is suggestive of
the fact that our comprehension of the interplay of factors that lead to various
kinds of suicidal behaviour still remains deficient. Psychological autopsy-based
studies of suicide victims have revealed that individuals who commit suicide have
had several contributing factors, including some specific personality traits and
even mental disorders (Pompili et al., 2004). Some of the associated risk factors
for suicide include age, sex, unemployment, other specific sociodemographic
characteristics such as religious affiliations, and presence of various psychiatric
problems (Hawton and van Heeringen, 2009; Mann et al., 2005).
A growing body of evidence has established a link between certain personality
factors and suicidality (Brezo et al., 2006). Personality traits characterize emo-
tional, behavioural, motivational, interpersonal, experiential and cognitive styles
which help us to cope with the environment. Given the perceptible significance
of personality to the development of suicidality, the dilemma remains as to which
direction one should look to identify the personality features that may be termed
as contributory. It is evident that there is not a straightforward causal link between
personality traits and suicidality. A more likely and realistic picture is that certain
personality features intermingle with eliciting stimuli along the intricate chain of
development of suicidal behaviour. However, the existing literature attempting to
explain the role of different individual concepts of personality in isolation remains
relatively deficient about arriving at definite conclusions about the influence of
personality traits on suicidality (Brezo et al., 2006). In light of this, in the present
chapter we attempt to concisely bring together the major research findings
linking personality and suicidality, so as to try to make the reader wholistically
conversant with the significance borne by different personality-related factors in
influencing suicidal behaviour. Depending on different models, these personality
factors have been named as neuroticism, agreeableness, openness to experience,
conscientiousness and extroversion (Costa and McCrae, 1988); extroversion,
40 Vijay Parkash and Updesh Kumar
psychoticism and neuroticism (Eysenck, 1990); harm avoidance, novelty seeking,
reward dependence and persistence (Cloninger et al., 1993); or emotional insta-
bility, compulsivity, antagonism and inhibition (Livesley et al., 1998) and so on.
Although some of the specific determinants of suicidality will be discussed in
detail in subsequent chapters of this volume, in the following sections we will
attempt to establish a broader linkage of the various personality factors explained
by different models with the varied aspects of suicidality.

The five-factor model of personality and suicidality

Keeping in view the trait-based descriptions of personality, the five-factor model
is considered the most comprehensive and widely accepted model to explain
personality (Costa and McCrae, 1992; McCrae and Costa, 1987). The five
personality dimensions explained by the five-factor model show clear innate
characteristics (Jang et al., 1996; Terracciano et al., 2010) and have been found
to be linked with varied psychiatric problems such as anxiety, depression, substance
use, and personality disorders (Hayward et al., 2013; Koorevaar et al., 2013;
Kotov et al., 2010; Weber et al., 2012).
Brezo and colleagues (2006) conducted a systematic analysis of the linkage
between personality traits and risk of indulgence in suicidal behaviour and
found that the two major dimensions of the five-factor model – neuroticism and
extraversion – were the most consistently replicated personality traits linked
with suicide-related behaviours. As anticipated, neuroticism-borne positive
association and extraversion were found to have a negative relationship with sui-
cidal behaviour. Higher levels of neuroticism were found to be positively linked
with suicidal behaviours including suicidal ideation, suicide attempts and com-
pleted suicide; whereas extraversion was found to serve as a protective factor
against suicidality (Brezo et al., 2006, as cited by Blüml et al., 2013). Heisel and
colleagues (Heisel et al., 2006) conducted a study on depressed older adults and
concluded that higher scores of neuroticism and openness dimensions of person-
ality were significantly correlated with suicidal ideation. Other studies on suicidal
ideation reveal that high scores on neuroticism and low scores on extraversion,
agreeableness and conscientiousness in a college student sample were associated
with increased suicidal ideation (Kerby, 2003); whereas, in another study on
university students, neuroticism emerged as a significant predictor for suicide
ideation (Chioqueta and Stiles, 2005). Blüml et al. (2013) put forth that
researches in this area also signify gender differences and conclude that gender
plays an important role in determining the influence of personality traits on sui-
cidality (Rozanov and Mid’ko, 2011). In another study on suicide ideation among
young adults, Velting (1999) reported that neuroticism was found in association
with suicidal ideation in females, while among male participants conscientiousness
was found to be negatively correlated with suicidal ideation.
Going from ideation to suicide attempts, similar findings were reported by
Useda et al. (2004) for the association between various facets underlying the Big
Five personality dimensions and suicide attempts among another sample of
depressed older adults. Giving consideration to personality factors associated with
 Suicidality and personality 41
completed suicides, a study conducted by Fang, Heisel, Duberstein and Zhang
(2012, as cited by Blüml et al., 2013) in an adult sample in rural China concluded
that a personality style characterized by a blend of high neuroticism and low
extraversion was found to be associated with increased suicide risk. In a more
recent study conducted on 2427 adult German participants by Blüml and
colleagues (2013), it was observed that the personality factors, extraversion,
conscientiousness, neuroticism and openness, and the presence of depression
were significantly associated with suicidality. Specifically, neuroticism and openness
were found to have significant direct association with suicide risk, whereas
extraversion and conscientiousness were found to be inversely associated and
serve as protective factors against suicide risk.
It has been seen in many studies that increased risk for suicidality is
found persistently linked to neuroticism (Brezo et al., 2006; Chioqueta and
Stiles, 2005; Fang et al., 2012; Heisel et al., 2006; Kerby, 2003; Useda
et al., 2004), which is often associated with negative affectivity and maladaptive
coping styles (DeNeve and Cooper, 1998; Gunthert et al., 1999). Hence, it can
be said that the linking pathway between neuroticism and increased suicidality
passes through negative affect and maladaptive coping. As opposed to high levels
of neuroticism, low levels of extraversion are associated with a negative perspec-
tive on life and hopelessness; whereas higher extraversion tends to promote
positive affectivity (DeNeve and Cooper, 1998; Duberstein et al., 2001), a path-
way that often links extraversion with reduced suicidal behaviour (Brezo et al.,
2006; Kerby, 2003; Fang et al., 2012).
Although neuroticism and extraversion are frequently linked with suicidality,
there is relatively less confirmation regarding the influence of the other person-
ality factors on suicidality. Though Heisel et al. (2006) found openness to be
associated with suicide ideation among depressed older adults, they pointed out
that, on the one hand, openness may enhance the probability of reporting suicide
ideation as tapped by self-report measures and, on the other hand, by means of
timely reporting of suicidality and thereby enhancing the chances of clinical inter-
ventions, openness may also reduce the actual risk of suicidal deaths (Heisel et al.,
2006). The linking pathways between openness and suicidal behaviours can
be traced in the findings which report a linkage of high levels of openness with
cognitive distortion, lack of insight and impulsivity (Piedmont et al., 2009,
2012). As has been reported by a few studies, low levels of conscientiousness
are related with increased suicidal ideation (Kerby, 2003; Velting, 1999), the
path that leads from conscientiousness to suicidality may be manifest in the
linkage of low levels of conscientiousness with impulsive tendencies, substance
abuse and deficits in active coping strategies (Hayward et al., 2013; Manuck
et al., 1998; Watson and Hubbard, 1996), which are the probable risk factors
for suicidal behaviours.

The Big Three personality dimensions and suicidality

Other than the currently popular five-factor model, researchers have
also tried to explore the relationship of Eysenck’s (1990) Big Three personality
42 Vijay Parkash and Updesh Kumar
dimensions with suicidal behaviours. Based on one such endeavour, Kumar
(1990) found that higher levels of psychoticism were positively associated with
suicidal ideation among a sample of university students. Some recent studies also
confirm this finding and assert that psychoticism is significantly related with sui-
cidal behaviour (Kerby, 2003; Singh and Joshi, 2008). In a study conducted on
250 college students, Singh and Joshi found significant associations of suicidal
behaviour with extraversion and psychoticism dimensions of Eysenck’s personal-
ity model. In their study suicidal ideation was significantly predicted by depres-
sion and the linking pathways between personality and suicidality emerged
through the medium of development of depression which was predicted by
neuroticism and psychotic personality dimensions. There are many other research-
ers who have found suicidality related to childhood temperament (Caspi et al.,
1996) and personality characteristics such as neuroticism and psychoticism
(Dyck, 1991; Nordstrom et al., 1995). Among the Eysenckian personality
descriptors, neuroticism, toughmindedness and social non-conformity have been
found to be significant correlates of persistent suicidal thoughts (Singh and Joshi,
2008; Statham et al., 1998). Extending support to the notions of other research-
ers, Kumar et al. (2013) have shown the linkage of the Big Three personality
factors with suicidal attempts by finding significant associations of the narrower
traits of impulsivity, violence and loneliness with increased likelihood of suicide
attempts.
There are many other researchers supporting this notion that some personality
characteristics (Akiskal et al., 2003; Heisel et al., 2006; Kochman et al., 2005)
seem to have the most important role. Supporting the linking pathways between
personality and suicidality, it has frequently been observed that impulsivity and
aggressiveness type of personality features (Mann et al., 2005; Rihmer, 2007),
impaired problem-solving capacity, a high level of neuroticism, and low openness
(Heisel et al., 2006; Stankovic et al., 2006) serve as risk factors for both attempted
and completed suicide. While the linkage of neuroticism with suicidality flows
through its underlying traits such as anxiousness, depressiveness, and mood
lability (Eysenck, 1987; Miller and Pilkonis, 2006), impulsive and aggressive
personality make-up directly prompts an individual to take extreme steps like
suicide. Though impulsivity and aggression are among the most crucial personal-
ity factors linked to suicidal inclination, we will not discuss them in this chapter
as Gvion and Apter will be specifically deliberating on their role in Chapter 5 of
this volume.

Temperament
Taking the genetically determined side of personality make-up, temperament is
considered as a constellation of structural behavioural characteristics that indi-
viduals have in their nature from birth and are relatively stable for the whole of
life (Yumru et al., 2008). It has been seen that temperamental traits are found to
be associated with suicidality in clinical samples as well as the general population.
In the case of suicide attempters, of the temperamental traits described by
 Suicidality and personality 43
Cloninger et al. (1993), harm avoidance is found generally higher, and self-
directedness and cooperativeness are found to be lower (Calati et al., 2008;
Rothenhausler et al., 2006). Yumru and associates have found that suicide
attempters had higher impulsiveness, harm avoidance, reward dependence and
self-transcendence (Yumru et al., 2008). They reported that in suicide attempters
harm avoidance and self-transcendence scores were higher and reward depend-
ence was lower as compared to non-attempters; also, a negative correlation was
found between reward dependence and number of suicide attempts. Indicating
the linkage through the medium of hopelessness, they found that harm avoidance
had a positive correlation with hopelessness among the suicide attempters.
Justifying it and in line with other researchers (e.g., Calati et al., 2008;
Rothenhausler et al., 2006), in suicide attempters, the harm avoidance score was
significantly higher and the self-directedness score was significantly lower than
normal controls (Yumru et al., 2008).
Another linking pathway can be traced due to the fact that, according
to Cloninger’s theory, a low level of self-directedness is a harbinger of personality
disorder and the likely presence of personality disorders among the suicide
attempters with a low level of self-directedness may be acting as an underlying
cause of suicidal behaviour (Yumru et al., 2008). Some other researchers also
assert that individuals with a high level of harm avoidance and a low level of self-
directedness are considered to have a ‘weak’ personality (Le Bon et al., 2004) that
might not be able to withstand the strains and may break down. Based on a more
recent study, Perroud et al. (2013) commented on the direct association of
severity of suicidal behaviour with higher levels of harm avoidance and novelty-
seeking. They concluded that besides impulsivity and anger-related traits, harm
avoidance was the only temperamental trait independently associated with a his-
tory of suicide attempts. Indicating the suicidal pathways through harm
avoidance, self-directedness, impulsivity and anger control, they suggested that
early detection of subjects displaying risk factors such as high harm avoidance
and low self-directedness, associated with high impulsivity and poor anger
control, may help the health care professionals to prevent suicidal behaviours
(Perroud et al., 2013).
Other models of temperament also mention such temperamental traits that
may be linked to an individual’s increased vulnerability to suicidal behaviour.
Using Strelau’s (1983) regulative temperaments as a focus of study, Parkash
(2010) found that the temperamental traits briskness and endurance correlate
negatively with maladaptive coping, hopelessness and depression and thereby may
be considered as protective factors, however, another temperamental trait perse-
veration correlates positively with anger, hopelessness and depression which may
be considered as the linking pathways to suicidal thoughts.
Considering other temperament models, many recent studies have focused
on affective temperaments and revealed a strong association between some
specific affective temperament types and suicidal behaviour (Akiskal et al., 2003).
In a comparative study on cyclothymic and non-cyclothymic bipolar-II
patients, Akiskal et al. found that cyclothymic individuals reported notably more
44 Vijay Parkash and Updesh Kumar
frequent suicide attempts and experienced more current hospitalization for sui-
cidal risk. In another study on juvenile inpatients with current major depressive
episode, Kochman et al. (2005) found that cyclothymic-hypersensitive tempera-
ment at baseline significantly forecast suicidal behaviour. Young et al. (1994/1995)
also reported similar findings that bipolar patients with cyclothymic history
reported a significantly higher number of prior suicide attempts. Henry and col-
leagues (1999) while studying the depressive and hyperthymic temperament in
relation to suicidal behaviour among bipolar patients, found that patients with
high depressive temperament scores had a history of significantly more frequent
suicide attempts (cited by Rihmer et al., 2009).
While investigating the affective temperament profile of consecutively hospital-
ized Italian psychiatric patients, Pompili and colleagues (2008) found the major-
ity of them with unipolar major depressive or bipolar disorder, and a significant
number (more than 60 out of 150) were a suicide risk at admission. They reported
that, compared to the non-suicidal patients, the suicidal psychiatric patients were
found to be significantly higher on depressive, cyclothymic, irritable and anxious,
and significantly lower on hyperthymic subscales of the TEMPS-A (Temperament
Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version).
Cloninger et al. (1998) had similarly concluded that rates of current depression
and prior suicide attempts were the highest among persons with cyclothymic and
depressive personality types.
Studying affective temperament among non-violent suicide attempters,
Rihmer et al. (2009) reported that depressive, cyclothymic, irritable and anxious
temperaments were significantly more frequent and common among suicide
attempters. The pathways running from temperament types to suicidality can be
traced to the findings that the different affective temperament types such as
depressive, cyclothymic, hyperthymic, irritable and anxious are trait-related man-
ifestations and usually the predecessors of the major depressive and mood disor-
ders (Akiskal and Pinto, 1999; Kochman et al., 2005; Rihmer et al., 2009). This
provides significant suggestive input on the affective temperaments serving as
probable predictors of suicidal behaviour.

Self-esteem
Going beyond the typical personality models, research evidence reveals that a
common variable and related personality factor linked to suicide is self-esteem
(Overholser et al., 1995). Self-esteem is considered to be linked to sense of
worthfulness. According to Overholser et al., individuals with high self-esteem
tend to be positive in their attitudes about themselves and are generally found
content with their lives. On the other hand, people who have low self-esteem are
considered to have feelings of incompetence and worthlessness, and a negative
view of themselves. As a link with suicidality it can be inferred that when a person
has a pessimistic and worthless view of himself or herself, then there becomes
a general likelihood of increased suicidal tendencies (Overholser et al., 1995). In
another study, Dori and Overholser (1999) also found low self-esteem as an
 Suicidality and personality 45
indicator of suicidal ideation. They observed that, compared with their non-
suicidal counterparts, suicide attempters had significantly lower self-esteem
and higher levels of depression and hopelessness. Connecting the findings with
self-esteem it was found that depressed and hopeless adolescents with adequate
levels of self-esteem were less likely to demonstrate suicidal behaviours as com-
pared to those with low self-esteem (Dori and Overholser, 1999). Rassmussen
et al. (1997) had also found significant positive association of suicidal ideation
with high depression and low self-esteem. Vella et al. (1996) found that suicidal
ideation was inversely correlated with self-esteem among a college population.
Suicidal ideation increases with declined self-esteem.

Personality disorders
Although the belief in ‘suicidal personality’ has by and large been discarded,
there remains an opinion that personality factors are of significance in
suicidal behaviours. The association between personality disorder and suicidal
behaviour has been identified by the researchers in this field. Personality disorders
play a role as significant risk factors for one’s chance to get involved in suicidal
behaviour. Psychological autopsy-based studies frequently show that individuals
with personality disorders have a considerable probability of indulging in suicide
attempts and they are found among suicide committers (Pompili et al., 2004).
Pompili and associates (2004) reviewed the empirically based literature from the
years ranging from 1980 to 2004 and identified studies dealing with suicide and
borderline personality disorder, narcissistic personality disorder, antisocial
personality disorder, and risk factors for suicide in personality disorders. Their
overview revealed that some personality disorders have a sturdy linkage to suicidal
behaviours and that identification of certain specific personality-related risk
factors may be used for the development of protective measures. Since personality
disorders have a substantial prevalence rate, prediction and prevention of suicide
among people with personality disorders are a major public health concern.
Personality disorders are psychiatric conditions which are characterized by an
unceasing mould of internal experience and behaviour that are nonflexible and
present in a variety of situations. These psychiatric conditions have a significant
influence on patients’ interpersonal relationships, and their functioning in social
and occupational settings. As far as their etiology and clinical features are
concerned, different personality disorders are heterogeneous in nature. It is the
combination of genetically determined temperamental traits and different
environmental events that determines the symptom complexes of personality dis-
orders. Each specific disorder has a specific and varying relative contribution of
genetic and environmental factors (Pompili et al., 2004). Researchers believe that
the estimated prevalence of personality disorders ranges from 6 to 13 per cent in
the general population (Samuels et al., 1994; Weissman, 1993). Seeing the preva-
lence of personality disorders among cases of attempted and completed suicides,
researchers opine that up to 77 per cent of suicide attempters (Engstrom et al.,
1997; Ferreira de Castro et al., 1998; Nimeus et al., 1997; Suominen et al., 1996)
46 Vijay Parkash and Updesh Kumar
and at least one-third (ranging from 31 to 62 per cent) of the victims of com-
pleted suicides (Brent et al., 1994; Cheng et al., 1997; Foster et al., 1997; Lesage
et al., 1994) have suffered from personality disorders. It has also been found that
suicide attempters with personality disorders have the highest level of repetition
(Suominen et al., 2000).
Serving as a significant risk factor for suicidal behaviour, personality
disorders have been found to predict completed suicides in the follow-up
(Allebeck et al., 1988; Paris, 1993; Stone, 1989). In post-mortem retrospective
interview studies and multiaxial diagnostic assessment-based studies, personality
disorders have been found to be prevalent with almost 57 per cent of suicide
victims, generally young victims (Lesage et al., 1994; Rich and Runeson, 1992).
It has also been found that there is a substantial likelihood of a history of suicidal
thoughts or attempts among subjects with personality disorders, and their
first- and second-degree relatives are also relatively likely to have indulged in
suicidal behaviours (Samuels et al., 1994).
In a study of fatal and non-fatal suicidal behaviour among adolescents,
Marttunen et al. (1994) found that among the adolescents with non-fatal
suicidal behaviour, approximately 45 per cent males and 33 per cent females
behaved antisocially and 17 per cent of victims of fatal suicidal behaviour met the
criteria for conduct disorder or antisocial personality disorder. It has also been
found that the risk of a serious suicide attempt was almost four times higher
among individuals with antisocial personality disorder as compared with those
without the disorder; and this risk is almost nine times higher in men under the
age of 30 (Beautrais et al., 1996).

Borderline personality disorder

Empirical evidence suggests that 9–33 per cent of all suicides are represented
by individuals with borderline personality disorder (Runeson and Beskow,
1991; Kullgren et al., 1986). Peterson and Bongar (1990) found a link of
chronic suicidality and repetitive suicidal crises with the behaviours that met the
criteria of borderline personality disorder. The finding received support from
Paris and Zweig-Frank (2001) who indicated that the diagnosis of borderline
personality disorders is significantly correlated with increased risk of eventual
suicide. Young people under the age of 30 were found to be at higher risk
(Friedman and Corn, 1987). The higher rate of linkage between borderline per-
sonality disorders and suicidal behaviour is reflected in different forms including
recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour
(Pompili et al., 2004).
Supporting a prevailing notion that considers borderline personality disorder
as the suicidal personality disorder, Mehlum et al. (1994) pointed out that the
features such as a lack of control of high intensity affects such as depression,
anxiety or anger, which may be the characteristic features of borderline personal-
ity disorder, may increase the tendency towards suicidal behaviour. Depression is
considered to be associated with suicidality in the majority of cases and the linking
 Suicidality and personality 47
pathways can be inferred in the fact that many researchers believe that in
borderline personality disorder there is a high prevalence of comorbidity with
major depression (Fyer et al., 1988). Standing by the assertion that there is a
strong link between borderline personality features and suicidality, Yen et al.
(2004) pointed out the association between each DSM-IV (Diagnostic and
Statistical Manual – IV) criterion of borderline personality disorder and aspects
of suicidal behaviour. According to Yen and colleagues (2004), the criterion of
the borderline personality disorder which is most strongly associated with suicidal
behaviour is affective instability. Impulsivity assessed as a diagnostic criterion
among patients with borderline personality disorder has also been found to be
related to suicide attempts in many cases. If the assessed borderline personality
disorder criteria also include hopelessness, then that is likely to increase the seri-
ousness of suicidal intent. It is believed that self-harm or suicidal behaviour is
central to the clinical picture of some personality disorders including borderline
personality disorder (Pompili et al., 2004).
Empirical studies have shown that among individuals having borderline person-
ality disorder, older age, impulsivity, antisocial personality traits, depressive mood,
and previous suicide attempts serve as risk factors for further suicidal behaviour
(Brodsky et al., 1997; Kjelsberg et al., 1991; Paris et al., 1989). Pompili et al.
(2004) also found that many suicide attempters with personality disorders had a
history of previous suicide attempts compared with those without personality
disorders. In addition to the personality disorders, adverse life events may act as
a catalyst to push high-risk individuals into actual suicidal crisis. Kelly et al. (2002)
found that suicide attempters experience adverse life events such as stressful events
at home, with the family or financially. It has been observed that changes in hab-
its, sexual difficulties, separation from wife or girlfriend, problems with in-laws,
and change in social activities are the events that occur relatively more often
among the suicidal patients having borderline personality disorder (Lesage
et al., 1994). If we look at the linking personality factors, on the basis of
derivations from clinical reports and longitudinal follow-up studies, Soloff et al.
(1994) concluded that in borderline personality disorder the probable risk
factors for suicidal behaviour include: (1) impulsivity, aggression, and hostility;
(2) alcohol and substance abuse; (3) antisocial traits; (4) severity of borderline
personality disorder; (5) comorbidity with affective disorder; and (6) repeated
previous attempts.

Narcissistic personality disorder

In a psychological autopsy-based study conducted by Apter and his colleagues
(1993), on a sample of 43 consecutive suicides that occurred among young
Israeli males during compulsory military service, schizoid personality disorder
was found to be the most common Axis II personality disorder (more than
37 per cent of victims having it) followed by narcissistic personality disorder
(more than 23 per cent of victims found affected by it). Based on a 15-year
comparative follow-up of psychiatric patients, Stone (1989) concluded that in
48 Vijay Parkash and Updesh Kumar
comparison with the patients without narcissistic personality traits, the patients
who suffered from narcissistic personality disorder had a significantly higher like-
lihood of having died by suicide. Stone further asserted that a heightened risk for
suicide has been found associated with narcissistic features in borderline person-
alities. The pathway linking it to suicide may be traced in the hypothesis that
narcissism might increase the suicidal vulnerability in people with intense self-
pride (justifiable or inflated) as any sudden unexpected drop in social position may
influence such a person more drastically than others and it might lead to suicidal
behaviour in the efforts to avoid facing society.

Antisocial personality disorder

In the domain of personality disorders, antisocial personality disorder also
tends to show a link with suicidality. Evidence exists to provide indications of
linking pathways between antisocial personality traits and suicidal acts. Studies
conducted on suicide attempters have shown that criminal behaviour or antisocial
personality disorder is a significant predictor of subsequent suicide attempts
(Bunglass and Horton, 1974; Morgan et al., 1976). There are other researchers
who confirm these associations of antisocial personality with suicidality. In a study
conducted by Garvey and Spoden (1980) it was found that suicide was attempted
by more than two-thirds of their patients having antisocial personality disorder.
Another group of researchers (Woodruff et al., 1971) reported that around a
quarter of the outpatients diagnosed with antisocial personality disorder attempted
suicide. A study conducted on a large group of people with sociopathic personal-
ity traits found that more than 10 per cent of them had attempted suicide
(Robins, 1966). Pompili et al. (2004) opine that suicide attempters are found
with generally more frequent social problems such as with marriage or love affairs.
Garvey and Spoden’s (1980) findings were similar, wherein they had reported
that most of the non-serious suicide attempts were more or less solely associated
to problems with some significant other. The finding in Garvey and Spoden’s
study showing the majority of suicide attempts by sociopaths as relatively safe and
‘non-serious’ provides evidence to support the notion that rather than killing
oneself, suicide attempts are used by sociopaths to act out their frustration and to
manipulate others (Pompili et al., 2004).
It has been clear by the preceding discussion that while considering the
associative linkage of suicidal behaviour with personality disorders, most of the
existing studies focus on cluster B personality disorders of DSM-IV including
borderline personality disorder, narcissistic personality disorder and antisocial
personality disorder. There is a heavy representation of individuals with one or
more cluster B personality disorders among those who attempt suicide, which
may often result in death and completed suicide (Pompili et al., 2004). According
to DSM-IV criteria, impulsivity is a key symptom of the behaviour of cluster B
personality disorder patients. These impulsive cluster B patients most of the time
look for a quick and sweeping resolution of their disturbing impulses. Moreover,
the need to be admired among the narcissistic individuals and the craving to
 Suicidality and personality 49
manipulate others among the antisocial individuals increase the risk of indulgence
in suicidal behaviours. Such individuals may use suicidality as an extreme whimper
for help if they do not receive enough support from the environment to gratify
their psychic needs.

Conclusion
Suicidal behaviour has long been a matter of research and scientific concern
since more than a million people die by suicidal means every year. Any effort
focused on suicide prevention requires a detailed in-depth understanding of all
the factors associated with the risk of suicidal behaviour. The research on these
factors provides a wide coverage including the genetic, biological, personological,
social and environmental factors that may be associated with suicidality.
Continuous efforts are being made to trace all the linking pathways of suicidality
so that their identification can help guide the use of appropriate preventive meas-
ures centring on the causative factors. Analysis of different research on personality
and suicidality has helped make certain linking pathways evident. Adequate per-
sonality assessment and the resultant identification of vulnerable personality traits
like neuroticism, impulsivity, aggression, emotional reactivity, harm avoidance,
self-directedness and the symptoms of various personality disorders are likely to
prove the key to determine the most effective preventive measures to safeguard
human lives against the maladaptive behaviour patterns of suicidality. Also, there
seems to be a dire need for more dedicated research focusing on very specific nar-
rower traits that are crucial to the understanding of suicidal dynamics. Future
research, therefore, should concentrate on tracing the roots of suicidal behaviour
rather than finding the surface-level triggering factors.

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4 Emotion dysregulation
and suicidality
Michael D. Anestis

Suicidality is a complex construct and numerous theories have emerged to

explain who is most vulnerable to suicidal desire and behavior and how those
individuals develop that vulnerability. A number of such theories have posited
that suicidal behavior serves at least in part as a method by which an individual
can escape acute crises. In Baumeister’s (1990) escape theory of suicide, he
posited that suicidal behavior can best be conceptualized as an effort to escape
from aversive self-awareness. He argued that, when in a state of aversive self-
awareness, an individual’s ability to resist impulses to engage in suicidal behavior
diminishes, thereby increasing the odds of an attempt that emerges explosively in
response to an acute affective state. Similarly, Mann et al. (1999) argued for a
diathesis-stress model in which individuals with high levels of trait impulsivity
(diathesis) encounter upsetting events (stress) and then respond to these acute
states with attempts aimed at escaping aversive sensations. A commonality across
these theories is the notion that, at times, suicidal behavior serves as a method to
avoid acute affective states. Building on these ideas, the notion that emotion
dysregulation might play an important role in suicidal behavior has become
commonly accepted.
Emotion dysregulation is a multifaceted construct that involves deficits
across a broad range of areas. These areas include the identification, understanding,
and acceptance of emotional states, the ability to persist towards goals while
upset, the ability to resist impulses while upset, and the degree to which an
individual exhibits a range of adaptive strategies for managing his or her emotions
(Gratz and Roemer, 2004). Numerous measures for assessing emotion
dysregulation exist and numerous subcomponents of the larger construct (e.g.,
distress tolerance, negative urgency, affective lability) have been subject to a
substantial amount of research and clinical attention. Indeed, difficulties with
emotion dysregulation have been tied to a number of problematic outcomes,
including binge eating, substance use, antisocial behavior, non-suicidal self-injury
(NSSI), and risky sexual behavior (e.g., Anestis et al., 2007, 2009; Buckner et al.,
2007; Glenn and Klonsky, 2010; Messman-Moore et al., 2010; Tull et al., 2012).
Psychiatric diagnoses characterized by difficulties with emotion dysregulation
have also been routinely associated with increased rates of non-lethal and lethal
suicidal behavior (e.g., borderline personality disorder; Paris and Zweig-Frank,
 Emotion dysregulation and suicidality 57
2001). Indeed, Dialectical Behavior Therapy (DBT; Linehan and Heard, 1992)
and Emotion Regulation Group Therapy (ERGT; Gratz and Gunderson, 2006)
have been demonstrated to be efficacious and/or effective psycho-social
approaches to the treatment of suicidality (e.g., Gratz and Tull, 2011; Kliem et
al., 2010; Linehan et al., 2006), thereby prompting an increasing belief in the
potential robust and proximal role of emotion dysregulation in suicidal behavior.
DBT and ERGT both teach broad emotion regulation and specific distress
tolerance skills aimed at enabling suicidal individuals to weather difficult and
upsetting moments rather than harming themselves. In this sense, the treatments
are posited to influence suicide-related outcomes by enhancing an individual’s
capacity to effectively regulate their emotions in the moment and enabling them
to opt to utilize means for regulation that are more effective and less costly than
a suicide attempt. This point is further supported by research that has linked
emotion dysregulation difficulties with suicidal ideation (e.g., Lynch et al., 2004;
Orbach et al., 2007).
The relationship between emotion dysregulation and suicidality becomes
more complex, however, when considering results from studies that have looked
specifically at suicidal behavior rather than ideation or a broad measure of suicide
risk. In a sample of depressed children, Tamas and colleagues (2007) reported
that suicide attempters did not differ on any facet of emotion dysregulation rela-
tive to children with suicidal ideation and suicide plans, but no suicide attempts,
children with only suicidal ideation, or children with no ideation but repeated
thoughts of death. Such results seem to echo previous findings linking emotion
dysregulation to suicidal ideation, but do not necessarily point to a direct and
incrementally valid association with suicidal behavior. Similarly, in a sample of
adolescent inpatients, Zlotnick et al. (1997) reported that attempters exhibited
greater levels of emotion dysregulation, but that emotion dysregulation did not
differentiate those with attempts from those with only ideation. In this sense, a
robust relationship between emotion dysregulation and suicidal behavior
(as opposed to ideation, which may in turn prompt behavior) does not appear to
be supported by these data.
One theoretical framework that appears to have substantial value in terms
of framing the complex relationship between emotion dysregulation and
suicidality is the Interpersonal-Psychological Theory of Suicidal Behavior
(IPTS; Joiner, 2005). The IPTS differs from other theories in that it dif-
ferentiates between the desire for suicide and the capability for suicide. Desire is
thought to be prompted by the joint presence of thwarted belongingness
(an individual’s sense that he or she lacks meaningful connections to others) and
perceived burdensomeness (an individual’s sense that he or she is a liability to
others and more valuable dead). The capacity, on the other hand, is thought
to be comprised of elevated pain tolerance and a diminished fear of death and
bodily harm. Although a portion of this capacity appears to be genetic (Smith
et al., 2012), it is largely theorized to be acquired through repeated exposure to
painful and/or provocative events, which lead to habituation to pain and fear.
The vast majority of individuals with suicidal desire will not have the capability
58 Michael D. Anestis
and the vast majority of those with the capability will not have desire. It is only in
the relatively rare combination of suicidal desire and capability that serious or
lethal suicidal behavior will emerge, thereby explaining why so many with ideation
do not attempt and why so many who attempt do not die. The primary hypothesis
of the theory – that both desire and capability must be present for serious suicidal
behavior to occur – has been supported across multiple samples (e.g., Anestis and
Joiner, 2011; Joiner et al., 2009; see Van Orden et al. 2010, for a thorough
review of the empirical evidence underlying the theory). The IPTS views suicidal
behavior as a planned pursuit of death and an outcome that does not emerge
suddenly in response to acute affect states. Emotion dysregulation is not viewed
as irrelevant; however, the nature of its relationship to each component of suicide
risk is thought to be nuanced.
Thus far, there has been limited research considering the association between
emotion dysregulation and suicidality through the lens of the IPTS. Anestis et al.
(2011) examined a sample of undergraduates and theorized that difficulties regu-
lating negative emotions would predict elevated suicidal desire (burdensomeness
and belongingness) but diminished acquired capability. They noted that the need
to immediately avoid aversive states may not be consistent with the nature
of suicidal behavior, in which pain and/or intense fear of death/bodily harm
must be experienced in the pursuit of death. The authors examined two sub-
components of emotion dysregulation – negative urgency (the tendency to act
rashly in an effort to reduce the intensity of negative affective states; Whiteside
and Lynam, 2001) and distress tolerance (the degree to which an individual can
function while upset in a manner consistent with functioning during euthymic
states; Simons and Gaher, 2005). Indeed, results from this study demonstrated
that difficulties with emotion dysregulation predicted elevated suicidal desire
and diminished acquired capability, measured both through self-report and a
behavioral measure of physio-logical pain tolerance. The somewhat counter-
intuitive finding between emotion dysregulation and the acquired capability has
since been replicated using a behavioral measure of distress tolerance as well,
increasing confidence that the effect is not spurious (Anestis and Joiner, 2011).
Although promising preliminary evidence, the above-mentioned findings
were found exclusively in relatively healthy undergraduate samples, thereby leav-
ing their external validity open to serious question. More recently, however,
similar research has been conducted using clinical populations. For instance, in a
sample of adults receiving residential treatment for substance use disorders, the
relationships between suicidal behavior and both borderline personality disorder
(BPD) and posttraumatic stress disorder (PTSD) were found to increase at higher
levels of distress tolerance (Anestis et al., 2012a, b). Neither disorder exhibited a
significant association with suicidal desire at low levels of distress tolerance
(greater difficulties with emotion dysregulation), but as an individual’s ability to
tolerate distress increased, so did the magnitude of the relationship between
disorder and suicide attempts. Furthermore, these effects held for attempts with
ambiguous intent to die, attempts with clear intent to die, and medically serious
attempts.
 Emotion dysregulation and suicidality 59
Although the acquired capability was not measured directly, when considered
alongside the previously reported positive association between distress
tolerance and the acquired capability, these findings speak to the notion that
individuals vulnerable to suicidal desire (e.g., those with BPD or PTSD) are more
likely to engage in suicidal behavior when they have developed the capacity
to do so. As noted before, the IPTS conceptualizes suicidal behavior as an
experience requiring a purposeful confrontation with fear (of death and/or severe
bodily harm) and either the presence or threat of physiological pain. In this
sense, the behavior is unlikely to yield the primary outcome desired by an
emotionally dysregulated individual in a moment of crisis: an immediate decrease
in the intensity of an aversive affective state. This stands in direct contrast to
behaviors such as binge eating and NSSI, which have been shown to be motivated
primarily by the drive to experience immediate relief (e.g., Smyth et al., 2007;
Nock and Prinstein, 2005). In this sense, such evidence indicates that suicidal
behavior may be, in some ways, qualitatively different than other problematic
behavior, not only in its greater potential for lethality, but also in the mental
and physical obstacles that impact the motives, function, and probability of the
behavior.
A reasonable concern when reading about findings like those from Anestis and
Joiner (2012) is that individuals with BPD or PTSD are unlikely to exhibit high
distress tolerance. The rareness, however, can be easily seen as strength of the
model. Although it is true that such individuals do not typically exhibit high dis-
tress tolerance, they also do not typically engage in suicidal behavior. Suicidal
behavior is certainly elevated in these populations relative to others; however, it
remains a low base rate phenomenon, so it seems reasonable to assume that the
typical presentation of either disorder would not be the most robust path towards
suicidal behavior.
Building on these findings, Anestis et al. (2013a) examined a sample of adults
receiving inpatient treatment for substance use disorders and found that distress
tolerance moderated the relationship between NSSI and suicide potential, with
the relationship becoming stronger at higher levels of distress tolerance. The
authors conceptualized suicide potential as a continuum extending from no prior
suicidal behavior, to one or more low lethality attempts, to a history of high
lethality suicidal behavior. The findings thus point towards the notion that even
NSSI, a robust predictor not only of past suicidal behavior (e.g., Nock et al.,
2006) but also future attempts (e.g., Cooper et al., 2005), may not be enough
on its own to facilitate suicidal behavior.
Taking this a step further, however, Anestis et al. (2013b) reported that low
distress tolerance (greater difficulties with emotion dysregulation) predicted a
greater number of lifetime suicide attempts, but that this relationship was medi-
ated by lifetime NSSI frequency. Put another way, the relationship between a
component of emotion dysregulation and suicidal behavior was explained by
the impact of a specific painful and provocative event (NSSI) frequently engaged
in by emotionally dysregulated individuals. This finding mirrored that of
Anestis et al. (2012), who found that the relationships between negative urgency
60 Michael D. Anestis
(a subcomponent of emotion dysregulation) and both the acquired capability
and suicidal behavior were mediated by lifetime exposure to painful and/or
provocative events. In this sense, it appears as though it is not the emotion dys-
regulation itself, but rather the behaviors engaged in by a subset of emotionally
dysregulated individuals, that explain the elevated rates of suicidal behavior in
emotionally dysregulated populations.
Such findings are entirely consistent with the IPTS framework. Data indicate
that the most frequently endorsed function of NSSI is intrapersonal negitive rein-
forcement in the form of immediate reductions in the intensity of negitive affect
(e.g., Nock and Prinstein, 2005). Furthermore, data indicate that engaging in
NSSI may truly offer such affective relief (e.g., Bresin and Gordon, 2013) and
that engaging in a greater number of episodes and/or methods of NSSI is
associated with a greater level of pain tolerance (e.g., Franklin et al., 2012; Hooley
et al., 2010; McCoy et al., 2010; Russ et al., 1999; Russ et al., 1992). Such find-
ings indicate that emotionally dysregulated individuals may engage in NSSI to
manage negative emotions. Because the behavior is effective in producing the
desired result, it becomes a common practice in distressing moments. Although
the individuals’ emotion dysregulation is initially associated with a lower capacity
to engage in lethal self-harm, over time the repeated episodes of NSSI increase
pain tolerance levels and provide practice with the notion of inflicting harm upon
one’s own body. As such, if and when suicidal desire becomes present – a distinct
possibility in emotionally dysregulated individuals – the capacity becomes more
likely to be present as well, thereby increasing the odds of serious or lethal suicidal
behavior.
Although no studies to my knowledge have directly tested this proposition, it
seems entirely plausible to me that this same path exists for any painful and/or
provocative experience utilized regularly as an emotion regulation strategy.
Something moderately threatening and/or painful is engaged in repeatedly and,
over time, the individual habituates to the fear and pain. The result is then two-
fold: the individual must engage in the behavior more often or with greater sever-
ity to get the same effect (affective relief) and the individual becomes bolder with
respect to pain and fear. In this sense, there could be an infinite number of paths
from emotion dysregulation to suicidal behavior, some more robust than others
(e.g., NSSI versus excessive exercise), but the path would always involve specific
behaviors facilitating suicidal behavior over an extended period of time.
In many ways, this model is counterintuitive. If emotionally dysregulated
individuals attempt and die by suicide at greater rates than non-emotionally
dysregulated individuals, how can I argue that emotion dysregulation itself is only
an indirect risk factor for suicidal behavior and, in fact, an obstacle for certain
aspects of risk? Here again, I’d point to the discrepancies between the frequency
of suicidal ideation versus suicide plans versus non-lethal suicidal behavior versus
death by suicide. With each step in that chain, the sample grows smaller. Most
who think of suicide do not make a plan. Most who make a plan do not make an
attempt. Most who make an attempt do not die. As such, it seems entirely plau-
sible that this painful and frightening behavior that runs in direct contrast to the
 Emotion dysregulation and suicidality 61
evolutionary imperative of self-preservation might be difficult and that the few
who ultimately engage in it acquire the capacity to do so with great effort over an
extended period of time. The data indicate that at least certain components of
emotion dysregulation serve as an obstacle to the acquired capability for suicide
even as they predict greater levels of suicidal desire. The model thus posits that
many emotionally dysregulated individuals will desire, and maybe even plan, for
suicidal behavior, but will not engage in the behavior itself. That being said: a
subset of those individuals will engage in emotion regulatory behaviors that are
painful and/or provocative (e.g., NSSI) and, over time, those individuals will
develop the capacity for lethal self-harm, eventually transitioning from ideation
and plans to behavior. Their discomfort with aversive affective sensations initially
placed them at a disadvantage for the acquired capability relative to the general
population, but that same emotion dysregulation led some of them to repeatedly
engage in behaviors that altered their relationships with death and pain and made
the notion of a suicide attempt less difficult. In the meantime, the general popu-
lation engaged in fewer of these behaviors and exhibited lower levels of suicidal
desire, leading to a lower rate of suicidal behavior, despite their initial advantage
on one aspect of risk.

Conclusion and future directions

Many aspects of this model remain untested empirically and the evidence base
that exists is in many ways preliminary. As such, it is important to consider the
findings within that context. Furthermore, some potential sources of confusion
should be clarified. It seems plausible that some may read this chapter and assume
that the message is that effective regulation of affect and the ability to tolerate
distress are harmful. This is not my argument. As is the case with many variables,
context is pivotal. In most environments, effective emotion regulation is a path
towards health and well-being. It is simply when this capacity – or at least
parts of it (e.g., distress tolerance) – is paired with suicidal desire that it becomes
potentially problematic. Indeed, the success of DBT in the treatment of suicidal
behavior (e.g., Kliem et al., 2010; Linehan et al., 2006) and numerous findings
linking effective emotion regulation to increased well-being (e.g., Quoidbach
et al., 2010) are strong evidence that the capacity to regulate aversive states is in
no way iatrogenic.
In this sense, the proposed model emphasizes the importance of nuance
when considering risk factors for a complex construct like suicidality as well as
the importance of empirically dispelling prominent myths regarding suicidal
behavior (Joiner, 2010). What makes an individual vulnerable to one aspect of
suicide risk (e.g., suicidal desire) does not necessarily make that same individual
vulnerable to other aspects of suicide risk (e.g., capacity for suicide). Similarly,
although some variables (e.g., emotion dysregulation) may in some ways serve as
an obstacle to certain aspects of risk (e.g., capacity for suicide), this is not to say
that individuals with elevation in that variable cannot overcome that obstacle.
Ultimately, the strength in a model such as this is that it aligns well with the fact
62 Michael D. Anestis
that such a small percentage of those with ideation make attempts and so few of
those who attempt die by suicide. There are many aspects to risk and that path to
lethal self-harm is not simple.

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5 Role of aggression and
impulsivity in suicide attempts
and in suicide completion
Yari Gvion and Alan Apter

Suicide is the tenth leading cause of death worldwide, accounting for

1.5 percent of all deaths in the Western world (Hawton and van Heeringen,
2009). About 25 suicide attempts occur for every fatal suicide (Simon, 2008).
Approximately 90 percent of individuals who commit suicide meet the criteria for
a psychiatric disorder (Cavanagh et al., 2003). However, despite the fact that
most suicide attempters suffer from psychopathology, most persons with
psychiatric disorders do not attempt suicide. Therefore other factors over and
above psychopathology must be involved. Predictors of suicidal behavior and risk
factors include a history of previous suicide attempts, certain demographic
variables, clinical symptoms, traits and states and issues related to medical and
social support (Hawton and van Heeringen, 2009; Gvion and Apter, 2012).
So it seems that suicide is multifaceted and rarely the result of any single cause
(Apter, 2010).
One of the major challenges for research in this field is the need to
define the role of personality and trait-like dimensions in predisposing
to suicidal behavior. The aim of this chapter is to review the past and
current literature on the long-known link between aggression, impulsivity, and
suicide.

Suicide and suicidal behavior

Suicide is an act of intentionally terminating one’s own life (Nock et al., 2008).
A suicide attempt is defined as such when the following characteristics are
present: (a) self-initiated, potentially injurious behavior; (b) intent to die; and
(c) a nonfatal outcome (Van Orden et al., 2010; Witte et al., 2008). Suicide
may be preceded by suicidal thoughts, threats, gestures, non-suicidal self-injuries,
and suicide attempts of various degrees of lethality, all of which are generally
lumped together under the rubric of ‘suicidality’. There is also some value
in separating out medically serious suicide attempts (MSSA) from the non-
medically serious suicide attempt (NMSSA) (Beautrais, 2001, 2003), as the study
of this subgroup can best shed light on actual suicide attempters (Marzano et al.,
2009; Levi-Belz et al., 2013).
 Role of aggression and impulsivity in suicide 67

Aggression and impulsivity: a single or

two distinct constructs?
There are a growing number of studies on impulsivity and aggression.
Yet a consensus definition of the constructs aggression and impulsivity remains
elusive and is beset by a lack of conceptual clarity (for review, see Gvion and
Apter, 2011). This is largely due to the confusion between terms such as
‘aggression’, ‘aggressiveness’, ‘impulsivity’ and ‘impulsive-aggression’.
In the psychological and psychiatric literature aggression is defined as any
behavior intended to harm another person who is motivated to avoid being
harmed (Baron and Richardson, 1994). Terms such as aggression and violence
are used to describe destructive behavior, angry feelings, hostile fantasies and
indirect attacks on objects (Gothelf et al., 1997).
Although the literature uses terms such as aggression, violence, irritability, and
anger interchangeably, it is important to specify differences and over-laps. Trait
anger is the tendency to feel anger more intensely, more often and for a longer
period of time than others (Deffenbacher et al., 1996). The definition of trait
irritability includes being angrier, in general and taking offense at the slightest
provocation as well as the propensity to be offensive in the use of aggressive
behavior (Bettencourt et al., 2006), trait irritability and violence are conceptually
related (Glasser, 1985) to trait aggressiveness (Caprara and Renzi, 1981) and the
construct of trait anger overlaps with trait aggressiveness (Buss and Perry, 1992).
There is also a difference between two forms of aggression: reactive and proactive
aggression. Reactive aggression (RA) is an aggressive response to a perceived
threat or provocation, and as such it is emotionally charged, poorly controlled,
and impulsive, whereas proactive aggression (PA) is defined as an unemotional,
highly controlled, and premeditated behavior that anticipates a reward
(Kemps et al., 2005; Conner et al., 2009).
Impulsivity is an ill-defined concept encompassing a broad range of behaviors
that reflect impaired self-regulation (Evenden, 1999; Whiteside and Lynam,
2001). Cyders and colleagues (2007) distinguish five facets of impulsivity:
sensation seeking, lack of deliberation, lack of persistence, positive urgency, and
negative urgency (the latter two meaning the tendency to act rashly in response
to positive and negative affective states, respectively). Patton and colleagues
(2005) define impulsivity in terms of attentional, motor, and non-planning
impulsiveness and look at impulsivity as a stable trait that can be evaluated using
personality questionnaires. Others assess behavioral impulsivity using measures
such as the Immediate Memory Task (IMT) (Keilp et al., 2005), or consider it as
a state that can be assessed by taking individuals’ subjective accounts of state
impulsivity (Michaelis et al., 2003). A recent meta-analysis found a significant but
rather small association between different measures across studies (Cyders and
Coskunpinar, 2011).
Given its robust relations to aggressive and delinquent behaviors, early
appearance in development, and overlap with domains of general personality,
68 Yari Gvion and Alan Apter
increasing attention is being paid to impulsivity as a predictor of aggressive
behaviors (Krueger et al., 1996). Some authors suggested that overlap between
aggression and impulsivity is robust and universal and that they should be
considered together, as a single phenotype (Mann and Currier, 2009), others,
however, believe they represent two distinct latent dimensions (Critchfield et al.,
2004). Be that as it may, the association among impulsivity, aggression, and
suicidality is well documented both in research and in clinical practice across
diagnoses (for review, see Gvion and Apter, 2011). Some recent studies have
suggested aggressive-impulsive behavior as the underlying link between a family
history of suicide and new attempts by probands especially in youth (Brent and
Melhem, 2008; Chachamovich et al., 2009).
One of the problems that arise when trying to decide which is most relevant
to suicidal behavior is the lack of clarity of the definitions: there are studies
that use the terms aggression and hostility synonymously (Michaelis et al.,
2004). Others use composites of constructs, namely impulsivity, hostility,
and aggression and terming them inter-changeably, as impulsive aggression
(McGirr et al., 2008, 2009). Problems also arise from the fact that aggressive
acts may be impulsive or premeditated, and impulsivity is a trait encompassing
spontaneous, poorly planned, and situationally inappropriate behaviors, without
necessarily including aggression (McGirr et al., 2008). It is also important to
distinguish between trait impulsivity and state impulsivity (Baca-Garcia et al.,
2005). From a suicidology perspective, they are all facets of the same underlying
predisposition, none a necessary and sufficient cause of the other, never preclud-
ing the other, but each a manifestation of a predisposition to suicide subsumed
under the impulsive aggressive suicide diathesis (McGirr et al., 2007; Brent and
Mann, 2005).

Aggression-impulsivity psychopathology
and suicidal behavior
Anger, aggression, and impulsivity are associated with suicide attempts.
Although current models suggest that aggression and impulsivity may contribute
to a summary factor predictive of suicidal behavior in patients with various types
of psychiatric diagnoses (Mann and Currier, 2009), many studies examined the
influence of each construct independently from the other.

Impulsivity, psychopathology and suicidal behavior

Numerous studies that have examined different aspects of suicidality in different
clinical populations have concluded that those with higher impulsivity levels
tend to be more likely to engage in suicidal acts (Forcano et al., 2009; Gut-Fay
et al., 2001; Yen and Siegler, 2003). Gut-Fay and and colleagues (2001) for
example, found that schizophrenic patients with co-morbid substance abuse
produced higher trait impulsivity scores and reported a higher number of
 Role of aggression and impulsivity in suicide 69
suicide attempts when compared to those without a history of substance abuse.
Similarly Swann and colleagues (2005) evaluated bipolar patients with and
without a definite history of attempted suicide using the Barratt Impulsiveness
Scale and a behavioral laboratory performance measure. They found that a history
of medically severe suicide attempts was associated with impulsive responses on
an immediate memory task. In another study Dumais et al. (2005a) noted an
association of suicide with high levels of impulsivity and aggression, in addition
to alcohol and drug dependence, and cluster B personality disorders. Finally,
Maser and colleagues (2002) compared the personality characteristics of three
groups of patients with affective disorders who were followed naturalistically for
14 years. Impulsivity was common to both suicide attempters and completers,
and together with assertiveness was the best predictor of completed suicide
beyond 12 months.
Impulsive and suicidal behaviors are among the most characteristic features of
cluster B diagnosis (Gunderson, 2001; Paris, 2002). Zouk and colleagues (2006)
investigated suicide completers with very extreme phenotypes, defined as a score
above the 70th and below the 30th percentile on the Barret Impulsivity Scale
(BIS). Compared to less impulsive suicide completers, the highly impulsive sub-
jects were more likely to have a cluster B diagnosis, exhibited higher measures of
aggressive behavior, and as well as a life-time and six-month prevalence of alcohol
and drug dependence.
Suicide attempts in alcoholics have also been linked to behavioral disinhibition,
impulsivity, and aggression (Mezzich et al., 1997). For example, Wojnar and
colleagues (2009) studied patients with alcohol dependence. A stop-signal
procedure was used as a behavioral measure of impulsivity. Forty-three percent of
the subjects reported life-time suicide attempts, of which 62 percent were
impulsive. The only significant factor that distinguished patients with impulsive
suicide attempts from patients with a non-impulsive suicide attempts and
non-suicidal patients was a higher level of behavioral impulsivity. Similar results
were obtained by Pompili and colleagues (2009) who compared a psychiatric
group with substance dependence and another without. The substance depend-
ent group had a tendency towards more impulsive aggressive personality
and a history of suicidal thoughts and behaviors. The statistical significance of
these finding was, however, low.
Studies of young populations consider the presence of impulsive behaviors
and maladaptive personality traits as possible factors that play a role in the risk
of suicide (Renaud et al., 2008). In a recent study Ghanem et al. (2013) found
that youth attempters had higher total scores and subscales of impulsivity than
controls.
It is not known whether impulsivity increases the risk of suicide independently
of aggressive traits (Baud, 2005) or if it is related to the medical severity of
suicide attempts. Some authors reported evidence of higher levels of impulsivity
in individuals who died by suicide than those who did not (Swann et al., 2005;
Dumais et al., 2005b) whereas others found that although people who attempt
70 Yari Gvion and Alan Apter
suicide tend to be more impulsive than people who do not, the actual act of com-
pleted suicide is often not made impulsively (Anestis et al., 2007). Simon et al.
(2001) reported that only 24 percent of survivors of near-lethal suicide attempts
had thought about their attempt for less than 5 minutes. Those who made their
attempt within 5 minutes of deciding to do so were less likely to have considered
another method of suicide. They also had a greater likelihood of discovery and a
lower expectation of death. Baca-Garcia and colleagues (2001, 2005) claimed
that impulsivity is a characteristic of non-lethal suicide attempts or suicide ges-
tures whereas planned suicide involves a more subjective element drawn from the
desired outcome and the perceived lethality of the act of self-harm. Baca-Garcia
and colleagues (2005) assessed attempt impulsivity (i.e., state) and attempter
(i.e., trait) impulsivity in an inpatient population. They found that impulsivity of
the attempter was not a good predictor of impulsivity of the attempt (i.e., attempt-
ing suicide without prior planning) and that non-impulsive attempts (i.e., those
that involved prior planning) were more lethal compared to impulsive attempts.
These findings highlight the importance of planning and preparation for suicide
in determining lethality. An additional study (Wyder and De Leo, 2007) surveyed
a community sample regarding past suicidal behavior. Only one quarter of these
described a pattern consistent with an impulsive attempt. Finally Witte and
colleagues (2008) compared adolescents who had planned a suicide attempt but
did not actually attempt; adolescents who did not plan a suicide but attempted;
and those who both planned and attempted suicide. They found that individuals
who planned suicide without attempting were significantly less impulsive than
those who attempted without planning and those who planned and attempted.
Furthermore, participants who attempted without planning were less impulsive
than those who both planned and attempted.
Other authors emphasized the mediatory role of the intent to die at the time
of the suicide attempt. Hawton (1986) observed that less than 50 percent
of subjects with a history of suicide attempts really wanted to die; he defined
their attempts as little-planned impulsive acts. Motives reported in impulsive
suicides ranged from escaping from an intolerable situation to manipulation
(Carballo et al., 2006; Oquendo et al., 2000).
When evaluating impulsivity within suicidality, research has focused on direct,
proximate, and indirect causal factors. For example, Mann and colleagues (1999)
propose a stress-vulnerability model of suicidality. Their model suggests that it is
not just stressors (e.g., job loss, end of a romantic relationship) that can lead an
individual to undertake a suicidal act. They postulate that, additionally, vulner-
ability towards experiencing more suicidal ideation and to acting in a more
impulsive manner needs to be present which then increases the likelihood of
individuals being more inclined to act on suicidal ideation. Furthermore,
impulsivity can increase risk for other suicide-related factors such as alcohol or
drug use, and thereby indirectly contribute to the risk of a suicide attempt
(Mann et al., 1999).
Joiner (2007) proposed the interpersonal psychological theory of attempted
and completed suicide which claims that in order to die by suicide an individual
 Role of aggression and impulsivity in suicide 71
must have both the desire and the capability. The desire to die by suicide stems
from a thwarted sense of belongingness and the feeling of being a burden on
others. However, the capability to engage in suicidal behavior is separate from the
desire to engage in suicidal behavior. The capability to die by suicide is acquired
through a process of habituation that allows the individual to overcome the pain
and fear associated with suicidal behavior. Pre-existing factors sometimes acceler-
ate the process. Thus, according to Joiner (2007), impulsivity is only distally
related to suicide: impulsive individuals may be more likely to have experiences
that are painful or provocative which, in turn, confer an increased risk of suicidal
behavior via habituation. Along the same lines, Witte et al. (2008) proposed that
certain behaviors may promote the individual’s capability of committing lethal
suicide, such as prostitution, drug use, self-mutilation, and violence. With
practice and repetition, the fear- and pain-inducing aspects of such provocative
behaviors are reduced, and they become rewarding.

Aggression, psychopathology and suicidal behavior

The correlation between aggression and suicidality has been studied across
psychiatric samples, and non-psychiatric populations. Popular conceptualizations
of suicide among schizophrenic patients have posited that many suicides of
schizophrenic patients involve the use of violent methods to commit suicide
thus implying a correlation between aggression and suicidality. Although some
studies did find that patients suffering from schizophrenia usually attempt
suicide with a potentially lethal method (Fenton et al., 1997), this was not
confirmed by other studies. Symonds and colleagues (2006) compared
suicidal intent, violence of method, and motive in patients suffering from
schizophrenia and adjustment reactions with self-harm. The schizophrenic
group did not significantly use more violent methods. The use of a violent
method was also not significantly associated with the presence of positive
symptoms in schizophrenia. Along the same lines Mitrev and Massaldjieva
(2004) found no significant relation between current aggressive behavior and
current suicide risk, as well as between lifetime aggression and lifetime
suicide behavior in male inpatients with schizophrenia and other psychotic
disorders. Finally, in a study by McGirr and colleagues (2006), it was found
that impulsive-aggressive behaviors did not play a role in schizophrenic and
chronic psychotic suicide.
Depression is also associated with suicide risk; several studies found a
correlation between suicide attempters suffering from depression and high levels
of impulsive and aggressive behaviors (Pendse et al., 1999), especially when
comorbid with Borderline Personality Disorder or substance use disorders (Cheng
et al., 1997). It remains unclear whether the association between impulsive and
aggressive behaviors and the risk of suicide is at least partly explained by Axis
I disorders that are commonly associated with suicide, such as major depressive
disorders. In an attempt to clarify that question, Dumais and colleagues (2005a)
compared a large sample of male suicide completers who died during an episode
72 Yari Gvion and Alan Apter
of major depression to living depressed males. They found that impulsive
aggressive personality disorders and alcohol abuse were two independent
predictors of suicide in major depression.
Bipolar disorder is also associated with suicidal behavior. Aggression but
not impulsivity appears to be a factor in this group. Oquendo and colleagues
(2000), and Michaelis and colleagues (2004) report that hostility was elevated in
bipolar suicide attempters relative to non-attempters.
In clinical practice, impulsiveness and hostility may function as suicide attempt
risk indicators because they indicate the likelihood of Borderline Personality
Disorder (BPD), which itself carries a heightened risk for suicidal behavior.
Therefore many studies investigated the association between suicide attempts and
violence among individuals with personality disorders, especially BPD (Zalsman
et al., 2006). One of the studies (McGirr et al., 2007) found that individuals with
BPD who died by suicide differed from those typically encountered in acute psy-
chiatric settings. They suggest that the lethality of BPD suicide attempts results
from an interaction between impulsivity and the violent-aggressive features asso-
ciated with cluster B comorbidity. Similar results were obtained by Brodsky and
colleagues (2006) who found that attempters with comorbid BPD and major
depressive disorder (MDD) had a higher number of lifetime suicide attempts, and
had higher levels of lifetime aggression, hostility and impulsivity, compared with
attempters with major depression only.
There is also a robust association of aggression and suicidal behavior in
hospitalized adolescents. Two types of suicidal behavior were found: one
characterized by depressive symptoms and another characterized by impulsivity
(Apter et al., 1988, 1995). This model of two types of suicidal behavior was
affirmed in a later study on younger male subjects (mean age 9.81) (Greening
et al., 2008). The association of aggression with suicidal behavior was also found
in non-patient adolescents. Conner and colleagues (2004) gathered data from a
community sample of 625 adolescent and young adult males. Impulsivity and
irritability were associated strongly with suicidal ideation after accounting for
alcohol dependence and other aggression-related constructs including psycho-
pathy. Vermeiren and colleagues (2003) conducted a school-based study, using
self-report measures. They observed that suicidal and violent adolescents shared
characteristics related to internalizing problems, aggression, and risk-taking
behavior.
In an attempt to study the relationship between aggression and suicide com-
pletion, different approaches have been taken. One of them compared medically
serious suicide attempters (MSSAs) to healthy controls. Trait aggression was
significantly higher in the MSSA group (Doihara et al., 2008), however, that
study did not include a non-medically serious suicide attempters (NMSSAs) con-
trol group. In another study personality-disordered individuals, particularly those
who are more impulsive and aggressive and who have a co-morbid depressive
disorder were found to have a higher risk for more frequent and more medically
severe suicidal behavior in comparison to individuals with Major Depressive
 Role of aggression and impulsivity in suicide 73
Disorder (MDD) or Bipolar Depression (BD) alone (Black et al., 1988;
McGlashan, 1987). Contrary to that, in a recent study our group compared
MSSA to NMSSA and to psychiatric non-suicidal controls. We found that aggres-
sion and impulsivity distinguished suicide attempters from non-attempters.
However, they did not distinguish the MSSA group from the NMSSA group and
thus did not predict the lethality of the suicide attempt (Gvion et al., 2014).
Gender is a factor that is closely related to suicide attempts and to the lethality
of the attempt. It has been found across different studies, that actual suicide is
more prevalent among men, whereas nonfatal suicidal behaviors are more
prevalent among women (Kessler et al., 2005). Aggression or one of its facets
(e.g., anger, violence) might be related to the difference found between female
and masculine suicidal behavior and completion.

Summary
Aggression-impulsivity are risk factors for suicide attempts. The association
between aggression, impulsivity, and suicidal behavior is well documented and is
based on decades of research and clinical practice. In analyzing the reciprocal
relationship between aggressiveness impulsivity and suicide behavior it is
important to make a distinction between acts (or observable behaviors, e.g. an
aggression) and traits or predispositions (e.g. impulsivity or aggressiveness),
which are non-observable, inferred constructs. It is also important to
better define the various suicidal behaviors. Looking at aggression and impulsivity
in near lethal attempters may be very different from examining these asso-
ciations in suicide attempt repeaters who frequently are present at emergency
rooms.
Nevertheless the literature is confusing and contradictory and not easy to
organize in a coherent manner. This is probably due to the difficulty in
defining and separating out these concepts and the fact that there is much
overlap between them. Thus, some of the data collected to date on the role of
aggression and impulsivity in suicide and suicide lethality needs to be reconsid-
ered in light of differences among the studies in definitions used, methods
employed, and the selected population. The future probably lies in looking at
some basic under-lying biological phenotypes such as those described in the work
of Mann and Currier (2009) or some of the sociological problem behavior
theories of Jessor (1991). Since aggression and impulsivity are so ubiquitous in
suicidal behaviors and so obvious a target for intervention, this area of enquiry
must be pursued despite all the inherent difficulties involved in such an endeavor.

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6 Psycho-social stress and
suicidal behaviour
Vsevolod A. Rozanov

The role of stress (stressful life events) in the suicidal process is well established.
At the individual level actual stress interacts with genetic predispositions,
personality features and protective factors producing positive or negative outcomes
(Wasserman, 2001). At the population level effects of stress are mostly modulated
by social factors which form the ‘framework’. For the human being the majority
of changes that need adaptation or produce frustrations and threats belong to the
social sphere. In modern industrialized societies with a high work load, rapid
changes in society, competitiveness, social inequalities and frequent readjustment
to new conditions, stress causes a variety of health problems which are mostly
psychosomatic by nature or involve mental health (Lundberg, 2006). These
effects are understood within the concept of psycho-social determinants of health,
i.e. factors that mediate the effect of social structure on individual and population
health outcomes and are conditioned by contexts in which these factors exist or
evolve (Martikainen et al., 2002).
The analysis of this concept presented by the above-mentioned authors
suggests a distinction between the macro-, meso- and micro-levels as a socio-
logical framework. It considers ‘psycho-social’ as a meso-level concept, which is
modified by macro-social factors. Macro-level in turn includes a set of
characteristics which relate to ownership and control of land and businesses, legal
and welfare structures, as well as distribution of income and other resources
between groups and individuals. Meso-level is understood as a more local set of
parameters, such as social networks and level of support provided by them, work/
activity control, effort/reward balance at work, security, autonomy, home control
and work/family conflicts. The central idea of a psycho-social explanation of
health outcomes is that social processes at macro- and meso-levels lead to
perceptions and psychological processes at the individual (micro-) level. These
psychological factors can influence health through direct psychobiological
processes or through modified behaviours and lifestyles. So, psycho-social stress
should be understood less at the individual level and more at the community level
as a response to deprivation, social injustice, inequalities or related events and
feelings. Rapid changes in social structures need to be taken into consideration
such as revolutions, countries’ disintegration, etc. This model is presented on
Figure 6.1.
 Psycho-social stress and suicidal behaviour 81

maero-Ievel meso-level meso-level individual biology

soeial soeial psyeho-soeial psyehologieal
health
strueture formations faetors faetors
behaviour

Figure 6.1 Schematic representation of psycho-social pathways to health or disease (from

Martikainen et al. (2002), by permission).

Rapid changes in society that modify macro-level factors, usually referred to as

transition periods are of the greatest interest to us within this chapter. Recently
these processes were widely represented in the post-Soviet space and in the coun-
tries of the former Soviet bloc. There are many publications which explore the
public health consequences of such transition. One of the first, Wolfgang Rutz
pointed out the dramatic lowering of life expectancy and excessive mortality from
external causes in the former USSR countries in 1993–2001, explaining this by
the advent of the severe stress that has overtaken hundreds of millions of its inhab-
itants (Rutz, 2006). Among the factors that accompany rapid societal changes
(macro-level disruption) Rutz discusses growing mental ill health, depression and
aggression, alcoholism and addiction, violence and suicidality, risk-taking behav-
iours and destructive lifestyles, the rise of cardio- and cerebrovascular diseases as
well as accidents, both in traffic and in workplaces. These negative manifestations
have deep roots in psychological mechanisms which include the loss of dignity and
identity, loss of status, helplessness, loss of control and capacity to be in charge of
one’s own life, the anomie and loss of values, impairment of social connectedness,
as well as the lack of existential cohesion and meaning in life (Rutz, 2006). These
psychological perceptions and frustrations are accompanied by biological mecha-
nisms involving stress hormones with their diverse effects that provoke various
diseases, possibly tackling genetic mechanisms (Schneiderman et al., 2005;
McEven, 2012; Rozanov, 2012a).
In concordance with these views, Kopp and Rethelyi (2004), looking at the
transforming societies, have pointed out that chronic stress is the main cause of
the morbidity and mortality crisis, and draw attention to such global psychological
models as depression and learned helplessness that form the basis for negative
health and behaviour outcomes. In turn, Ginter and Simko (2010) stressed that
the main causes of mortality in the post-totalitarian Europe are the cardiovascular
diseases and external causes. They also stressed the role of unhealthy life styles and
alcohol consumption.
Actually the idea that psycho-social stress is a factor of great influence that
impairs health has been around for many years (Guntem, 1977). It was pointed
out that consumption of alcohol, alcoholism, psychosomatic syndromes, as
well as consumption of drugs and tobacco and mental ill health together with
82 Vsevolod A. Rozanov
criminality can serve as important indicators of chronic psycho-social stress. On
the other hand, it was noticed that when measuring the impact of societal stress
it is difficult to differentiate between stressors, indicators of stress and indicators
of coping behaviours (Guntem, 1977). Further it was stated that the population
statistics of myocardial infarction and cerebral stroke may be referred to as clear
indicators of the level of psycho-social stress in society (Denisova et al., 2005;
Egido et al., 2012). Nevertheless, suicide was not very clearly identified among
this set of psycho-social stress indicators, possibly due to the complexity of this
phenomenon and its dependence on many other factors, all of which is very
difficult to untangle.
We are going to demonstrate that changes and variations in suicide rates
observed in different countries undergoing rapid socio-economic transitions can
be understood to a great extent as the result of the changing level of psycho-social
stress. We believe that the concept of psycho-social stress provides additional
possibilities for understanding variations in suicide, sometimes clearer than
Durkheim’s sociological theory that explores the integration and regulation of
society as the main internal factors and which are very difficult to measure. To
support this, we analyze changes in suicide mortality in the 15 new independent
states that appeared on the world map after the USSR collapsed on the eve of the
year 1992. Suicide rates changes over a certain historical period (from 1980 to
2010) will be compared with other and stress-related diseases’ mortality
rates. The information source is the European Health for All Database (EHAD)
provided by the WHO web-site. For most ‘post-Soviet’ countries the above-
mentioned database contains data starting from the 1980s, when they were still
Soviet republics, up to 2011–2012. Here we are going to discuss psycho-social
stress effects while previously we explored these data mainly from the point of
view of the role of alcohol consumption (Rozanov, 2012b).
It is well known that for the last 30 years the most prominent fluctuations in
suicide rates were observed in the post-Soviet era. These dramatic fluctuations
that contrast with the stable situation in European Union countries (see Figure
6.2A) have been analyzed by researchers repeatedly (Mäkinen, 2000; Rutz, 2006;
Varnik and Mokhovikov, 2009; Varnik et al., 2010; Kõlves et al., 2013). All
authors agree on the role of stress in the observed fluctuations. Discussion centres
on such factors as ‘community syndrome of excessive morbidity and premature
mortality’, ‘economic distress’, and the ‘general pathogenic social stress’ which
accompanies political changes and social disorganization on the peak of processes
of disintegration and further transition to a different macro-level social structure.
It was noticed by all authors that the developments in suicide have been very dif-
ferent in various Eastern European countries, and that the same causes cannot
apply to all of them though high stress on the societal level has been involved.
From this point of view it is interesting to compare changes in suicide mortality
with other stress-related mortality indices – all external causes, cardiovascular and
cerebrovascular mortality (Figure 6.2B). It is clear that these indices had the same
temporal pattern as suicides which are also in full accordance with the concept of
psycho-social stress.
 SDR, suicide and self-inflicted injury, all ages per 100,000
40
A

30

20

10

o
1970 1980 1990 2000 2010 2020
EU members before May 2004 CIS

900
B
800

700

600

500

400

300

200

100

0
1980 1990 2000 2010
1,320 SDR, diseases of circulatory 1,360 SDR, cerebrovascular
system, all ages per 100,000 diseases, all ages per 100,000
1,340 SDR, ischaemic heart 1,720 SDR, extern al cause injury
disease, all ages per 100,000 and poison, all ages per 100,000

Figure 6.2 (A) Suicide rates in the EU and the 12 former USSR countries and (B) stress-
related mortality in the post-Soviet space, for 100,000 of population.
Source: European Health for All Database (WHO).
84 Vsevolod A. Rozanov
As can be seen in Figure 6.2A the average suicide rate fluctuations very well
reflect the social and economic processes and transformations taking place in the
country in the given historical period. Thus, with the beginning of ‘perestroika’
(the democratization and openness initiative which started in 1985), the level of
suicides decreased, reached a quite acceptable level (20 per 100,000) and stayed
at that figure up to 1991. It is important to notice that this period was full of
social optimism, a feeling of positive change, a turn towards more open discussions,
transparency, justice, freedom and contacts with the foreign countries, which of
course meant a lowering of psycho-social stress. However, economic problems
had been accumulating and very soon the situation changed completely. The
collapse of the USSR (the very end of 1991) provoked a sharp increase in the
number of suicides (60 per cent increase compared to 1985–1986 data), which
remained very high till 1995. These fluctuations were connected with the
economic problems in society, especially the ‘shock therapy’ during privatization,
as well as such adverse factors as loss of identity, internal migration and several
armed conflicts which took place in the post-Soviet era during the painful period
of 1991–1997. Suicide rates started to decrease after 1995, but only after the
economy had started to stabilize. Still this short decrease was followed with a new
sharp increase which coincided with the economic crisis and default in the Russian
Federation in 1998. This rise was short-term and after it suicide indexes started
going down all over the post-Soviet territory up to the present moment, as can
be seen from Figure 6.2A.
This stress involved all the population in the whole country, but as we will see
further the reaction to it with regard to suicide rates was very diverse in different
parts of the former empire. This is the main subject of our discussion, and we are
going to support the idea that existing attitudes to suicide, restrictions or
permissions regarding certain forms of self-destructive behaviour and possible
‘canalization’ of psycho-social stress are the main mechanisms that create variations
in suicide rates in different cultures under similar stressful conditions. To prove
this, we are using an approach in which countries are classified by the level of
suicides and the changes of different indicators under stress are compared within
the groups that are formed on the basis of the similarity of suicide rates. Our
conclusions are based on qualitative and visual perception of graphs depicting the
time changes in mortality indices in the different countries that emerged after
the fall of the USSR.
One can see variations of suicide rates between republics which were
once united in one country in Figure 6.3. As can be noted from the data provided,
the figures might be eight times different (for example, during the Soviet times,
the suicide rate in Lithuania reached 32 per 100,000 and in Armenia the rate was
4 per 100,000). The most remarkable issue is that in Figure 6.3 it is possible to
see two distinct groups of republics inside the USSR and further when they
became independent. The first group unites high suicide rate (HSR) countries.
In this group there are all the Baltic republics (Latvia, Lithuania and Estonia), all
the Slavic republics (Russia, Ukraine and Belarus) and Kazakhstan. The second
distinct group unites low suicide rate (LSR) countries. Here we can see all the
 Psycho-social stress and suicidal behaviour 85
Caucasus republics (Georgia, Armenia, Azerbaijan), and three Middle East
republics (Tadzhikistan, Turkmenistan, Uzbekistan). Also, a medium suicide rate
group can be identified in Figure 6.3 which is represented by Moldova and
Kirgizstan, which is not so distinct.
It is obvious that HSR and LSR countries are clustered geographically and
united by certain common features from the point of view of economic
development and cultural peculiarities. High rate countries are united by their
northern location, dependence of their economies on industrial development
and world economic tendencies, a high urbanization level, and multinational
population. In other words, these are ‘modernist’ type countries that are
integrated into the global economic and social processes. In such countries many
of the culturally specific features gradually decrease, giving way to more global
tendencies. The majority of the populations in the particular set of countries that
belong to the HSR group profess Christianity, except Kazakhstan where half of
the inhabitants are Muslims.
The LSR countries are diverse in their religions (Georgians and Armenians
are Christians while Middle Asia peoples are Muslims), but all of them have
lower levels of economic development, they are mostly peripheral agricultural
economies, with profound ethno-cultural specificity, almost mono-ethnic with
very traditional meso-social systems (families, communities, villages, etc.).
All these countries are located in southern peripheral regions (Caucasus and the
Middle East). They are historically destined to resist global tendencies, trying to
preserve their own mentality, culture, way of life and the specific social and
manufacture structure.
However, the existence of the ‘medium suicide rate group’ is less
understandable – it is rather complicated to explain what Moldova and
Kirgizstan have in common other than the suicide rate. To avoid this ambiguity,
we will further consider only those groups of countries that clearly differ
from each other. We are aware of the fact that this is a limitation of our analysis,
however, at this stage we believe it is necessary to present the most logical part
of it.
It is necessary to say that for more than 70 years of the existence of the
USSR, all countries (the former republics) were united politically, economically
and ideologically within one union; but as can be seen from Figure 6.3, they have
kept profound differences in suicidal behaviour. Such stability is not a surprise.
When speaking about aggregate suicide rates, all the countries in the world are
known to have their national level which keeps respective countries at more or less
the same ranking position in the general list, even though certain variations are
possible (Makinen and Wasserman, 1997). Besides, a stable gradient of increasing
suicide activity can be observed when moving from West to East and from South
to North along the Eurasian continent (Cantor, 2000; Bertolote and Fleischman,
2009). This may be also observed inside large countries and it can also be seen in
modern Russia and Ukraine. Historical national levels of stability and geographi-
cal gradients of suicide rates are important markers of the existence of some
strong factors which determine this stability in contrast to other causes of death.
 SOR, suicide and self-inflicted injury, all ages per 100,000
50 Armenia
A Azerbaijan
Belarus
40
Estonia
Georgia
Kazakhstan
30
Kyrgyzstan
Latvia
Lithuania
20
Republic of Moldova
Russian Federation

10 Tajikistan
Turkmenistan
Ukraine
o Uzbekistan
1980 1990 2000 2010

SOR, suicide and self-inflicted injury, all ages per 100,000

50

B
40

Armenia

30 Azerbaijan
Georgia
Tajikistan
20 Turkmenistan
Uzbekistan

10

o
1980 1990 2000 2010

Figure 6.3 Suicide rates in 15 former Soviet republics, all genders, all ages. General overview
(A); highlighted low suicide rates group (B); and high suicide rates group (C).
Source: European Health for All Database (WHO).
 Psycho-social stress and suicidal behaviour 87

SDR, suicide and self-inflicted injury, all ages per 100,000

50

c
40

Belarus
Estonia
30
Kazakhstan
Latvia

20 Lithuania
Russian Federation
Ukraine
10

o
1980 1990 2000 2010

Figure 6.3 (Continued)

This may be due to different complex reasons, but mostly may be understood as
‘cultural resistance’ (Makinen and Wasserman, 1997).
Deeper analysis of Figure 6.3 gives a lot of interesting observations. First, sharp
fluctuations in suicide rates for the last 30 years were typical only for the HSR
countries. In LSR countries (Caucasus and the Middle East republics) all of the
occurring changes of psycho-social stress that have influenced suicidal behaviour
in the Slavic and Baltic ethnicities had no effect, judging from their suicide rates.
Thus, at first glance we can suppose that there are countries that are contrastingly
different from each other in terms of ‘high suicide rate and sharp reaction to the
psycho-social stress’ and ‘low-suicide rate and blunted reaction to psycho-social
stress’. On the other hand this conclusion is based only on suicide rates as indica-
tors. However, reactions to psycho-social stress are not only confined to suicide
rate, but are represented by mortality from other stress-related diseases, homi-
cides, traffic accidents and other causes, as was mentioned by Rutz (2006) and
other authors. This is very well confirmed by Figure 6.2B which shows, that a
temporal pattern of mortality due to these reasons was actually the same as
changes in suicide rate. It means that stress was actually displayed, and further-
more detailed data will confirm it. On the other hand it was suicide particularly
that varied so much in the differing cultural and geographical clusters.
Another important fact becomes obvious when gender differences in suicide
rates are represented. The data provided by Figure 6.4 show that social and
economic problems of the period of transition impacted the female population
much less compared to the male population (Figure 6.4A–A1). Actually almost
all excessive suicide mortality in the period from 1989 to 1997 was due to suicide
 SDR, suicide and self-inflicted injury, all ages
per 100,000, male
90
A
80

70
Belarus
60 Estonia

50 Kazakhstan
Latvia
40
Lithuania

30 Russian Federation
Ukraine
20

10

o
1980 1990 2000 2010

SDR, suicide and self-inflicted injury, all ages

per 100,000, male
90
A1
80

70
Armenia
60
Azerbaijan
50 Georgia

40 Tajikistan

Turkmenistan
30
Uzbekistan
20

10

o
1980 1990 2000 2010

Figure 6.4 Suicide rates in former USSR republics, gender aspect (A–A1: suicide among
men in HSR and LSR countries; B–B1: suicides among women in HSR and
LSR countries in positions that best reflect changes).
Source: European Health for All Database (WHO).
 SOR, suicide and self-inflicted injury, all ages
per 100,000, female
20

15
Belarus
Estonia
Kazakhstan
10 Latvia
Lithuania
Russian Federation
Ukraine
5

o
1980 1990 2000 2010

SOR, suicide and self-inflicted injury, all ages

per 100,000, female
20

B1

15
- Armenia

- Azerbaijan

- Georgia
10
- Tajikistan

- Turkmenistan

- Uzbekistan
5

o
1980 1990 2000 2010
Figure 6.4 (Continued)
90 Vsevolod A. Rozanov
in males from HSR countries. The pattern of change of male suicides in the
LSR countries was different – there was no marked rise in rates at the respective
period of time. As a result, differences in suicide rates between HSR and LSR
countries increased. At the peak of the rise (1995) in HSR countries rates in males
varied from 52.54 per 100,000 (Ukraine) to 86.82 (Lithuania) with the mean
68.78, while in LSR countries variation was from 1.65 (Azerbaijan) to 15.31
(Uzbekistan) with the mean for this group 8.43 per 100,000. Thus the estimated
ratio between HSL and LSR countries for male suicides reached 8.16. Moreover,
in HSR countries suicide rates in males have peaked on average to 75 per cent in
the period from 1986 to 1995.
Presentation of suicide rates in females (Figure 6.4B–B1) reveals that women
in HSR countries also have higher rates than in LSR countries though the
differences are not so marked as among males. According to EHAD, in women
corresponding indices in the LSR group varied from 0.19 (Azerbaijan) to
4.07 (Uzbekistan) with the mean 2.21 in LSR countries and from 8.54 (Ukraine)
to 15.28 (Lithuania) with the mean 12.02 per 100,000. So, the estimated average
HSR/LSR ratio in female suicides reached 5.43. In HSR countries women also
showed the rise in the period from 1986 to 1995 on average to 23 per cent.
From these figures and calculations as well as from the diagrams it is clear
that excessive mortality shortly after the fall of the USSR almost all befell males
in HSR countries (Figure 6.4A–A1). Among men and women from LSR
countries there was no substantial reaction to the occurring social and economic
perturbations, and since the time of being part of the USSR up to the present
moment there has been a gradual decrease in suicide rates (Figure 6.4, A–A1,
B–B1). These smooth positive changes are in contrast with pronounced peaks in
suicide rates among men in the Baltic and Slavic states. There is a temptation to
conclude that Caucasus and the Middle East republics did not suffer so much due
to disintegration of the union, but we are going to show that this may be a wrong
conclusion.
Substantial differences in suicides in post-Soviet countries can be explained
from several points of view, but the economic factor is the first to be noted.
It goes without saying, that Russia, Ukraine, Belarus, Kazakhstan and the Baltic
countries underwent huge losses as a result of economic difficulties, general
market disintegration, rapid mass privatization, impoverishment of huge
contingents, sky-rocketing social inequality, etc. No doubt it impacted people’s
lives severely at a certain period of history. There is no doubt that these stressful
changes involved all former republics, including the peripheral regions. The
Caucasian and Middle East countries suffered even more due to their peripheral
location and specialization regarding industrial development. In this respect we
consider it useful to look at other indicators of psycho-social stress – mortality
rates from the disease traditionally related to stress, specifically, ischaemic heart
disease. These data are provided in Figure 6.5, where the countries are again
clustered according to their suicide rates.
It is clear that when looking at ischaemic heart disease mortality, differences
between HSR and LSR countries practically disappear. If we take the chosen
 Psycho-social stress and suicidal behaviour 91
‘reference’ countries from contrasting clusters (Armenia and Lithuania), male
mortality rate according to EHAD from these pathological states in Lithuania is
comparable with the male mortality rate in Armenia (534 per 100,000 vs. 532 per
100,000 in 1995). Mortality rate among females is even higher in Armenia (347
and 318 per 100,000 respectively). Moreover these data clearly indicate
that the mortality rate among men and women from such types of stress-related
diseases does not differ very much, though in females it is marginally lower than
in males. A similar picture can be observed when mortality rates from a wider
range of diseases of the circulatory system and cerebrovascular diseases are
analyzed (not presented here in the diagrams, but clear from the database). This
is very well supported by recent studies that prove the role of psycho-social stress
as a risk factor for cerebrovascular diseases (Egido et al., 2012). Differences
between two groups of countries are also not very marked if we take such
indicators of psycho-social stress such as traffic accidents and traumatic injuries.
We are not able to present corresponding diagrams here due to limited space.
We believe that these data can be interpreted as a shining example of the fact
that psycho-social stress hit all post-Soviet countries at approximately the same
level. It becomes apparent when cardio-vascular pathologies mortality rates
and especially circulatory system diseases are considered. These pathological
states are known as diseases with a strong psychosomatic component and with
stress-dependent pathogenesis. From this an important deduction can be
drawn regarding mortality rates from suicides that differentiate the countries so
much. These differences are induced by psycho-social stress that touched,
as we state, all countries to a more or less similar degree, but were strongly
modulated by culturally conditioned levels of attitudes, traditional restrictions or
permissions for such an act as suicide in the particular society, culture or ethos.
This resulted in a marked rise in suicides in HSR countries and a blunted rise in
LSR countries. In other words, the problem of historically established differences
in suicide rates is actually the problem of cultural tolerance towards such types
of self-destructive acts as suicide. This coincides with the opinion of other
authors who put culture, religion, norms and traditions forward as factors that
most strongly influence national suicide rates (Cantor, 2000; Cheng and
Chau-Shoun, 2000; Wasserman, 2009).
If we take this point of view, the HSR and LSR clusters can be seen a result of
how stress was ‘finding its way’, but less a result of the differences in stress itself.
Both northern and southern nations, males and females when facing crucial
points in their history were being forced to go through the collapse of the coun-
try that had provided security, relative economic stability, independence from
critical phenomena in a more global economic context, suffered considerable dif-
ficulties, socio-economic and existential problems. The differences in suicidal
behaviour are called forth by certain life roles, behaviour patterns, and ethno-
cultural norms and traditions typical to this or that particular ethnicity as they
have been formed historically.
Some evidence to prove our reasoning is also found in gender differences in
suicidal behaviour in HSR and LSR countries. It is well established that males
 SDR, ischaemic heart disease, all ages per 100,000, male
800

700

600 Belarus
Estonia
500
Kazakhstan
400 Latvia
Lithuania
300
Russian Federation

200 Ukraine

100

o
1980 1990 2000 2010 2020

SDR, ischaemic heart disease, all ages per 100,000, male

800

700

600
Armenia
500 Azerbaijan
Georgia
400
Tajikistan
300 Turkmenistan
Uzbekistan
200

100

o
1980 1990 2000 2010 2020

Figure 6.5 Mortality rates from cardio-vascular diseases among men and women in HSR
and LSR countries.
Source: European Health for All Database (WHO).
 Psycho-social stress and suicidal behaviour 93

SDR, ischaemic heart disease, all ages per 100,000, female

600

500

Selarus
400 Estonia
Kazakhstan
300 Latvia
Lithuania

200 Russian Federation

Ukraine

100

o
1980 1990 2000 2010 2020

SDR, ischaemic heart disease, all ages per 100,000, female

600

500

Armenia
400
Azerbaijan
Georgia
300
Tajikistan
Turkmenistan
200
Uzbekistan

100

o
1980 1990 2000 2010 2020

Figure 6.5 (Continued)

complete suicides much more frequently than females, and consequently

suicide is often considered as a ‘male phenomenon’ (Rutz and Rihmer, 2009).
Nevertheless it is a subject of great cultural influence how suicide is viewed among
males and females (Beautrais, 2006; Canetto, 2009). In this respect, the consider-
able predominance of male suicides in the Slavic and Baltic countries (5–6 times
higher) can be regarded as the consequence of cultural ‘permissions’. Not only
94 Vsevolod A. Rozanov
suicide is seen as ‘allowed’, it is actually sometimes encouraged as a positive male
behavioural pattern (the way ‘to solve all problems’, ‘save face’, ‘go away with
dignity’ and so on). Suicides among men and women in LSR countries may be
examined from the same point of view. Here male suicides are less dominating
(just 2–3 times higher than in females). At the same time, we should keep in mind
that these countries’ culture does not support any type of suicide. Apparently, this
has an impact mostly on the male population and as a result we can see lower
indexes and a lower male–female ratio in LSR countries.
With regards to the role of psycho-social stress, correlations between suicide
rates and alcohol consumption in the given environment should be also viewed.
The role of alcohol in suicides at the national level in the former USSR has been
discussed in suicidology many times. Analyzing the situation, Värnik and
Wasserman (1992), and later Wasserman et al. (1994) have pointed out that
significant decline in suicide rates in the republics of the former USSR in 1984–
1988 was observed shortly after the introduction of the anti-alcohol policy.
Logically restrictions of alcohol sale and lowering of the consumption at the
national level were supposed to be factors in suicide prevention (Wasserman and
Värnik, 1998) and possibly it really saved many lives. On the other hand it may
explain the lowering of suicides and other external causes’ mortality while the
synchronous lowering of cardiovascular and cerebrovascular mortality (Figure
6.2) is not so easy to understand following this reasoning. Besides, the problem
of alcohol is very complicated. Official data in the USSR were far from reality due
to the availability of home-made alcohol, the amount of which, according to
different sources, made up 25–40 per cent of the official figures (Feldbrugge,
1989), so the efforts of the government maybe were not very effective. Very soon
after the USSR collapsed alcohol consumption as well as alcohol-related mortality
went up especially in the HSR countries (Nemtsov, 2003; Pridemore, 2006). In
other words, we may see a concurrent pattern of changes, which is most likely
associated with psycho-social stress. As societal optimism grows, the consumption
of alcohol goes down, and vice versa. This process is accompanied with the effect
of ‘mutual reinforcement’ of the oscillations in alcohol consumption and suicide
rate. Alcohol can play a compensatory role in depression and suicide tendencies
(Liu et al., 1998; Thomas, Randall and Carrigan, 2003), especially for younger
people, though it can have a negative impact in terms of suicide planning for older
people and in a long-term perspective (Blow et al., 2004; Sher, 2006). The
relationship between alcohol and suicidality is also strongly determined by a
culture that functions as a moderator between stress, suicidality and alcohol
consumption. While in one given country with traditional style of drinking there
is a strong correlation between alcohol consumption and suicide, when several
countries are taken into consideration, such factors like wet or dry drinking
cultures have a greater influence (Ramstedt, 2001) and correlations between
suicides and alcohol are not found while the impact of economic factors remains
remarkable (Kõlves et al., 2013).
It must be also taken into consideration that the collapse of the USSR had
certain peculiarities; it was not only the case of economic difficulties. Dismantling
 Psycho-social stress and suicidal behaviour 95
of the socialist system, often fair but having now lost its social attractiveness, and
transition to the capitalist way of life, alluring with its welfare, intensified the
polarization of society, which in itself became an additional source of stress. This
was also the result of the harsh and rapid large-scale privatization (King, Hamm
and Stuckler, 2009). These processes were accompanied by economic hardship,
unemployment, population impoverishment, decline in health-care resources and
weakening of government control over the alcohol and drugs market. From this
point of view, the collapse of the USSR was a rather unique ‘natural experiment’
where the population effects of psycho-social stress could be clearly registered and
studied and the fact that there is a long-lasting interest in the health and suicide
consequences of this geopolitical event confirms it.
Summing up, we can state that the approach used in this chapter (dividing all
post-Soviet countries into two groups based on historically determined suicide
levels) allows the promotion of the role of psycho-social stress as a factor of
increased suicide mortality during the period of transition from one social-
economic system to another. We consider that here we can see the classical
influence of macro-level factors on the meso-level, which is moderated by the
micro-level (personality) according to Martikainen et al. (2002) with the central
role of psycho-social stress. It is necessary to notice here that stress in Russian
culture refers not only to a personal perception but is generally understood as a
societal process (Petila and Rytkonen, 2008). This possibly reflects one more
dimension of perception of stress in society – the conceptual tool in interpreting
social processes and popular discourse widely used in contemporary life.
On the other hand we must consider the complicated and ambiguous character
of the concomitant phenomena, the interconnection between stress and alcohol
consumption, the heterogeneity in mortality rate fluctuations caused by national
features during the switch to a market economy, mixed populations and migration
processes (King et al., 2009; Kõlves et al., 2013). Our analysis is qualitative,
not quantitative. Sometimes it reveals reflections of the insider, not only
scientific interest. Nevertheless it indicates that the interpretation of data on
the reactivity of suicide rates in different countries to serious psycho-social stress
at a certain historical period is explained with ethno-cultural peculiarities.
National traditions, the significance of cultural norms, the ability to preserve
one’s own identity and values under the pressure of global tendencies seem to
be important factors that determine variations in suicidal behaviour and its
historical dynamics.

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7 From social adversity
to psychological pain
A pathway to suicide
Philippe Courtet and Emilie Olié

The World Health Organization (WHO) estimates about 1.5 million deaths
by suicide per year worldwide by 2020. Emile Durkheim (Durkheim, 1897)
viewed suicide as a social fact. According to his theory the variations in suicidal
rate on a macro-level could also be explained by society-scale phenomena rather
than individual’s feelings and motivations. Nowadays, suicidal acts may be best
understood within a stress-vulnerability model, where it is assumed that only
vulnerable patients, when submitted to environmental stressors, will kill them-
selves. We will discuss how social adversity and psychological pain interact in this
model and help in a better understanding of suicidal process at individual level.

Social crisis
If suicide is a major health problem in occidental countries, it is not yet the
case in developing countries. On the one hand, it cannot be excluded that it is
due to the lack of epidemiological data. On the other hand, it could suggest that
economic expansion may be associated with increased suicidal risk because it
exposes more people to crisis and bankruptcy. Moreover, according to Durkheim’s
theory (Durkheim, 1897), economic development would lead to the destruction
of the social protections afforded by traditional communities and the increase
of individualism that would favour suicide. In addition, both prosperity phases
and financial crises would influence suicidal rates because they disturb the
normal course of economic life. If prosperity phases increase suicidal rates,
European suicide rates would have increased between 1945 and 1975. But the
reverse was observed: stagnation in the suicide rate during economic expansion
and increase in young people parallel to the increase in unemployment.
Epidemiological data show that the richer a country is (reflected by the gross
domestic product), the higher the level of suicide. However, in occidental
countries, wealth and suicide vary inversely: the poorest outlying urban areas are
the most affected by suicide (Baudelot and Establet, 2013). A recent series of
publications in high-ranking scientific journals have examined the impact of the
current economic recession on suicide rates in European populations. Stuckler,
Basu, Suhrcke, Coutts, and McKee (2009) have reported a significant increase in
suicide mortality at ages younger than 65 years in relation to the increase
 From social adversity to psychological pain 99
in unemployment in 26 European countries between 1970 and 2007; un-
employment being a strong indicator of the socio-economic situation of a
country. Moreover, social labour market protections interacted with the effect of
unemployment on suicide rates. Every US$10 per person increased investment in
active labour market programmes induced a significant reduction of the effect of
unemployment on suicides. Thus, in the twenty-first century, three major points
have to be highlighted to underline a possible relationship between economic
crisis and suicide:

• the suicide rate of employees is becoming more similar to the suicide rate of
workers while working conditions are getting worse;
• an increase of suicide rate for young working men has been observed since
1970, i.e. the beginning of the oil crisis;
• suicides occur in the workplace, sometimes serial suicides in (inter)national
companies (i.e. France Telecom).

High risk populations

Since the early study of Durkheim (1897) that demonstrated the relationship
between suicide and social factors, many authors have repeatedly shown that
social and economic factors are associated with spatial and temporal variation in
suicide occurrence (Rezaeian et al., 2005). Theories of suicidal behaviour suggest
that the desire to die can arise from the disruption of interpersonal relationships.
A theory of Joiner et al. (2005) attributes suicide to an individual’s acquired cap-
ability to enact self-harm, perceived burdensomeness, and thwarted belonging-
ness. Perceived burdensomeness is a mental state characterized by the belief that
others would ‘be better off if I were gone’.

Isolated elderly
Among this population, identified socio-environmental correlates include: popu-
lation density (Hempstead, 2006; Middleton et al., 2006), proportion of elderly
people (Aihara and Iki, 2003), and single person households (Hempstead, 2006).
Single person households are considered a measure of anomie (‘personal feeling
of lack of social norms’) and this has been used to construct Congdon’s Social
Fragmentation Index, but only using people younger than 65 years of age
(Whitley et al., 1999). Living alone can induce the feeling of being at odds with
social norms feeling. Rurup et al. (2011) have reported that having a low social
network and feeling alone were associated with the occurrence of suicidal idea-
tion. The elderly are more prone to be isolated. Purcell et al. (2012) have dem-
onstrated a significant main effect of family connectedness on suicide ideation in
depressed adults over 50 years old. It may suggest that having a stronger connec-
tion to family members decreased the likelihood of reporting suicide ideation. In
addition, in a study of 26 European countries, Yur’yev et al. (2010) found a
negative association between the social representation of people over 70 years old
100 Philippe Courtet and Emilie Olié
and suicide. Perception of the elderly as having higher status, recognition of their
economic contribution and higher moral standards, and friendly feelings towards
and admiration of them were inversely correlated with suicide mortality. Suicide
rates were lower in countries where the elderly live with their families more often.

Prisoners
The global prison population in 2008 was estimated at 9.8 million with a
median rate of imprisonment of 145 prisoners per 100,000 persons, most of
whom are aged between 18 and 44 years (Walmsley, 2009). If the excess mortal-
ity from suicide in prison is a fact that nobody can ignore (Fazel et al., 2011),
the existence of a persistent increase of suicidal risk even after release is more
confidential. The risk of suicide has increased eight-fold for men, and 36 times
for women compared to the general population (Pratt et al., 2006). Familial
disruption, poor attainment, social disadvantage, substance abuse, isolation,
unemployment, and psychiatric morbidity are each associated with suicide. But
the fact remains that as a society we are failing a group of particularly vulnerable
individuals, whose interdependent social and health problems fall too easily
between compartmentalized community services. Suicides in released prisoners
reflect not only shortcomings in agencies involved, but ultimately society’s
attitudes to rehabilitation and re-integration.

Psychosocial stress
At the individual level, the transition to the suicidal act is usually precipitated by
psychosocial stress. Nearly all suicide victims have experienced at least one or
more adverse life event within one year of death (concentrated in last few months).
Interpersonal conflict brought the greatest risk of suicidal act, followed by rela-
tionship breakdown, forensic events, unemployment, job problems, financial
problems, bereavement, and domestic violence. Some of the risk associated with
interpersonal events, forensic events, unemployment, and loss events is independ-
ent of mental disorder (Foster, 2011). All these factors are related to social
features and threaten the social status of the individual. Indeed, such events
decrease the potential for social investment defined as the ratio between the social
value of an individual to others and their social burden on others (Allen and
Badcock, 2003). When this ratio reaches a point where social value and social
burden are approaching equivalence, the individual is in danger of social exclusion
and becomes hypersensitive to signals of rejection.
Social bounds are essential for the survival of humans. Thus, when threatened
with exclusion, individuals either adapt their behaviours in order to increase
the degree of social acceptability promoting a return to baseline or may adopt
aggressive behaviour including antisocial or self-injurious behaviours (Williams,
2007). This is in line with Durkheim’s altruistic suicide, which takes place when
a subject identifies with a social group for whom he or she is willing to sacrifice
his/her own life.
 From social adversity to psychological pain 101

Suicidal vulnerability
Forty years of clinical as well as scientific research have produced evidence that
environmental factors alone may not explain the suicidal act. The proposed
understanding of the clinical model of suicidal behaviour is a model of stress
vulnerability. It is now accepted that only individuals harbouring suicidal vulner-
ability, when subjected to stressors, commit the act (Mann, 2003). Suicidal
vulnerability has been demonstrated to be underlain by stable traits enduring
all through life related to genetic, biological, cognitive abnormalities as well as
clinical characteristics:

• personal and familial history of suicide, impulsive aggressive personality traits,

hopelessness and neuroticism;
• serotonergic system and hypothalamo-pituitary axis dysfunction;
• dysfunctional emotional and cognitive processing such as deficits in
problem solving, altered decision-making relying on dysfunctional prefrontal
regions;
• role of genetic and epigenetic factors.

Social exclusion
Early traumatic life events are strongly associated with suicidal vulnerability.
Retrospective cohort and longitudinal studies have shown that childhood
exposure to a harmful environment, such as sexual abuse, emotional neglect,
disturbed relationship with parents or parental mental illness, have a devastating
effect and dramatically increase the risk of suicidal behaviour (Agerbo et al.,
2002). According to the theory of attachment (Bowlby, 1977), the perception of
being rejected or neglected in childhood would, in adulthood, lead to rejection
sensitivity and the perception of feeling unwanted in general – and hence con-
tribute to suicidal risk (Ehnvall et al., 2008). In addition, alterations in
decision-making (Jollant et al., 2007), a putative suicidal endophenotype involved
in the ability of the individual to make choices in daily life (Courtet et al.,
2011), are correlated to the occurrence of problematic affective relationships
(Jollant et al., 2007). When exploring decision-making capacities of patients
with a past history of suicidal act, it appears that they tend to keep on choosing
options with high immediate rewards but disadvantageous long-term outcomes,
whereas patients (without any past suicidal history) and healthy controls learn to
avoid these options and turn towards choices with low immediate gains but long-
term benefits (Jollant et al., 2005). Interestingly, this pattern of responses is
similar in ostracized animals, which have an impaired inhibition against
eating non-nutritive foods and avoidance of less tasty, nutritive foods (Baumeister
et al., 2006). Using functional MRI, prefrontal regions associated with suicidal
vulnerability (Jollant et al., 2008, 2010; van Heeringen et al., 2011) have
also been involved in studying response to rejection-related stimuli. Indeed, com-
pared to controls, suicide attempters had increased activity in the right anterior
102 Philippe Courtet and Emilie Olié
cingulate cortex in response to mildly happy versus neutral faces and increased
activity in the right orbitofrontal cortex in response to angry versus neutral faces
(Jollant et al., 2008). These results may indicate that suicide attempters could be
less prone to detect positive social cues and more sensitive to signals of rejection.
To study exclusion, a paradigm based on a virtual ball-tossing game (Cyberball
Game) was developed: while playing, subjects are either included or excluded by
other players. In response to exclusion, healthy controls showed hyperactivation
of the dorsal anterior cingulate and the right ventral prefrontal cortices
(Eisenberger et al., 2003). Moreover, Bolling et al. (2011) have found greater
functional connectivity of the anterior cingulate cortex to regions of the default
mode network during social exclusion. These results show that exclusion is salient
for humans and relies on regions involved in both emotion regulation and execu-
tive functions. Interestingly, emotional support through supportive messages may
attenuate social distress associated with exclusion. Functional MRI showed that
participants who experienced greater attenuation of social pain exhibited lower
ventral anterior cingulate cortex and higher left lateral prefrontal cortex activation
(Onoda et al., 2009). It may suggest that emotional support enhances cognitive
inhibition through lateral prefrontal cortex, which regulates emotional distress
relying on the cingulate cortex.

Social and psychological pains

Being excluded or rejected signals a threat for which reflexive detection in the
form of pain and distress is adaptive for survival (Williams, 2007). Social pain is
defined as the unpleasant experience associated with potential or actual damage
to one’s sense of social connection or social value (owing to social rejection,
exclusion, negative social evaluation or loss) (Eisenberger, 2012; Eisenberger and
Lieberman, 2004). Indeed, for Shneidman (1993) psychological pain or ‘psych-
ache’ is ‘the introspective experience of negative emotions such as dread, despair,
fear, grief, shame, guilt, frustrated love, loneliness and loss’ and relies on the
frustration of psychological needs. Thus we assume that social pain should be
considered as a subtype of psychological pain emerging from the threat of affili-
ation. Unbearable pain, particularly psychological pain, is a frequent theme of
suicide notes. Suicidal acts should be considered as the expression of an attempt
to escape from this psychological suffering. Using visual analogic scales, our
group has recently reported that depressed patients with a recent or past history
of suicide attempt expressed significantly higher levels of psychological pain than
depressed patients without any history of suicide attempt (Olié et al., 2009). The
intensity of psychological pain has been associated with suicidal ideation inde-
pendent of depression (Lester, 2000; Mee et al., 2011; Olié et al., 2009).
High psychological pain is associated with a history of suicide attempt
(Flamenbaum, 2007, 2009; Holden at al., 2001; Mills et al., 2005), suicide plan-
ning (Mee et al., 2011), and suicidal intention (Flamenbaum, 2007). However,
the association between psychological pain and suicide attempts has not always
been replicated (Lester, 2000; Pompili et al., 2008). Psychological pain was found
 From social adversity to psychological pain 103
to predict suicide attempts, but not suicidal ideation in the general population
(Flamenbaum, 2009; Troister, 2009). On the contrary, in a cross-sectional
study, psychological pain was predictive of suicidal ideation in suicide attempters
(Flynn and Holden, 2007). In a two-year follow-up study, the authors also
reported that psychological pain contributed to the statistical prediction of
suicidal ideation, independent of depression and hopelessness (Troister and
Holden, 2012). Similarly to social pain and suicidal vulnerability, psycho-
logical pain relies mainly on the prefrontal cortex, associated with suicidal
behaviour (review in Jollant et al., 2011; van Heeringen et al., 2011). Increased
cerebral blood flow in the right dorsolateral prefrontal cortex, the right inferior
frontal gyrus, the left inferior temporal gyrus and the right occipital cortex
was reported in depressed patients with high levels of psychological pain in
comparison to those with low levels of pain (van Heeringen et al., 2010).
People may seek death through suicide as a means of relief from a painful inter-
nal state (Orbach et al., 2003). Clinical experience suggests that suicidal ideation
can function as a coping mechanism, in that some people are able to tolerate high
levels of pain and/or disability by telling themselves that if their distress becomes
unbearable, they at least have the option of ending their distress through suicide.
In other words, suicidal behaviour becomes a problem-solving behaviour in order
to ‘stop the painful flow of consciousness’ (Shneidman, 1993). Indeed, the role
of painful defeat or entrapment in suicidal process was highlighted by the cry of
pain mode (O’Connor et al., 2008; Panagioti et al., 2012) and motivations to
escape from painful self-awareness were mentioned in the escape theory of suicide
(Baumeister, 1990).

Therapeutic perspectives

Promoting social bounds

Interestingly, the quality of social support is a protective factor for suicide.
Contacting people by telephone one month after being discharged from an emer-
gency department for deliberate self-poisoning may help reduce the number of
re-attempted suicides over one year (Vaiva et al., 2006) independent of the effect
of the identification of subjects at suicidal risk and the implementation of a crisis
intervention. Religion is another protective factor against suicide (Dervic et al.,
2004). Beyond the protective nature of a religious affiliation through the moral
opposite of suicide objection, we could assume that religion promotes social links
and favours affiliative needs.
As social exclusion may play a role in the suicidal process, future research
focused on prosocial pathways through oxytocin/vasopressin system is justified.
Examination of animal research provided evidence that the oxytocin system is
involved in response to social separation. The intranasal administration of oxy-
tocin reduces aversion to angry faces, a signal of rejection and salient emotion to
study suicidal vulnerability (Evans et al., 2010). Lower levels of oxytocin in cer-
ebrospinal fluid have been reported in suicide attempters in comparison to both
104 Philippe Courtet and Emilie Olié
patients without a history of suicide attempt and healthy controls (Jokinen
et al., 2012).

Relieving pain
There is increasing evidence that physical and psychological/social pains not only
overlap in colloquial language, but also at the clinical and neuroanatomical levels:
both states may involve suffering and activate the ‘pain matrix’ (experiencing
social distress activates the insular, cingulate, and secondary somatosensory cor-
tices) (Courtet et al., 2011; Eisenberger, 2012; Kross et al., 2011). Interestingly,
in a population-based study, we recently reported that people with a past history
of suicide attempts were more prone to consume prescribed opioid drugs than
subjects having a lifetime history of depression without a suicidal act and healthy
controls (Olié et al., 2013). Despite the fact that pain was not measured during
the follow-up period, we hypothesize that subjects with a history of suicide
attempt have an increased pain perception, assessed by an increased consumption
of opioid analgesics. Because people carrying suicidal vulnerability may perceive
high levels of psychological pain, it may lead practitioners to prescribe analgesic
drugs for undifferentiated states of physical or psychological pain. The implica-
tion of endogenous opioid systems in suicide needs further investigations.
μ-opioid receptors have long been implicated in the modulation of responses to
emotional stressors, in the quality of parental attachment (Moles et al., 2004;
Copeland et al., 2011). If psychological pain is the core of the suicidal act,
relieving it efficiently is thus needed to prevent suicide.
A single infusion of ketamine, a well-known analgesic drug, leads to a rapid
resolution of suicidal ideation in patients with treatment-resistant major depres-
sive disorder (DiazGranados et al., 2010). However, the reduction of suicidal
thoughts remains to be attributed to either the antidepressant or analgesic effect.
One on-going study is now investigating the specific anti-suicidal ideation effect
of intravenous ketamine in depressed inpatients (www.clinicaltrial.gov). Further
studies are needed to test the efficacy of analgesics on psychological pain and
suicidal risk.

Conclusion
Suicidal mortality is evitable and should be prevented. To succeed, a
double approach is needed: to promote social protections by the community and
to develop pharmacological targets for vulnerable people. On the one hand
psychosocial stresses leading to social pain are environmental factors pre-
cipitating the suicidal act. On the other hand, it is suggested that suicidal
vulnerability is associated with an increased perception of psychological pain.
Psychological pain seems to be a common construct for understanding
suicide and social exclusion should be closely considered in the suicidal
process. Assessment of such pain may have important implications in intervention
research, considering that psychological pain could be a therapeutic target
 From social adversity to psychological pain 105

Stress Vulnerability Suicidal act

• Social adversity • Hypersensitivity to psychological pain/negative social cues

• Social devaluation • Neuropsychology : alte red decision-making
• Neuroanatomy : dysfunctional prefrontal cortex
pr • Biochemistry : opioidergic system (?)
~
eil
~
o
c:
Psychological/Social iil
eil
Pain
Pain perception

~
:::J
"'0
!!!
Social support

Figure 7.1 Stress-vulnerability model including social/psychological pain (proposed by

the authors).

on its own. New avenues for improving the understanding of physiopatho-

logy and treatment of suicidal behaviours will be discussed in the light of
psychological/social pain (Figure 7.1).

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8 Clustering and contagion of
suicidal behaviour
Ella Arensman and Carmel McAuliffe

Internationally, there is growing public and professional interest in clustering

and contagion in suicidal behaviour. There are indications of increasing
clustering and contagion effects in suicidal behaviour associated with the rise of
modern communication systems (Larkin and Beautrais, 2012; Robertson et al.,
2012). Yet, the research in this area and information on effective response
procedures and prevention strategies are limited (Haw et al., 2013; Larkin and
Beautrais, 2012). Even in recent times, Boyce (2011) referred to the lack of
research as ‘Suicide clusters: the undiscovered country’. The methodological
approaches in assessing clustering and contagion of suicidal behaviour are
wide-ranging and internationally, there is a lack of consistency regarding the
definition of clustering and contagion and regarding the statistical techniques
assessing spatio-temporal aspects (Haw et al., 2013; Larkin and Beautrais, 2012;
Mesoudi, 2009).

Defining suicide clusters and contagion

Internationally, there is a lack of consistency in defining suicide clusters, which is
partly due to limited data and absence of controlled studies. Most studies so far
included narrative reports of potential suicide clusters without appropriate
statistical verification.
A frequently used definition to indicate time-space clustering (point cluster) is

a temporary increase in the frequency of suicides within a small community

or institution, relative to both the baseline suicide rate before and after the
point cluster and the suicide rate in neighbouring area.
(Gould, Wallenstein, and Kleinman, 1990;
Haw et al., 2013; Joiner, 1999; Mesoudi, 2009)

Larkin and Beautrais (2012) went a step further and introduced an operational
definition:

A suicide cluster is a series of three or more closely grouped deaths within

three months that can be linked by space or social relationships. In the
 Clustering and contagion of suicidal behaviour 111
absence of transparent social connectedness, evidence of space and time
linkages are required to define a candidate cluster. In the presence of a strong
demonstrated social connection, only temporal significance is required.

A concept introduced in recent times is the so-called echo clusters, which refers
to ‘the occurrence of subsequent, but temporally distinct clusters of suicide,
which take place in the same location after an initial suicide’ (Hanssens, 2010;
Larkin and Beautrais, 2012).
Another type of suicide clusters is being referred to as mass clusters, and is
commonly defined as ‘a temporary increase in the total frequency of suicides
within an entire population relative to the period immediately before and after the
cluster, with no spatial clustering’. Mass clusters are typically associated with high-
profile celebrity suicides that are publicized and disseminated in the mass media
(Haw et al., 2013; Hegerl et al., 2013; Ladwig et al., 2012; Mesoudi, 2009;
Stack, 2000).
Based on a recent review, contagion is a concept derived from the study of
infectious diseases and increasingly applied to cluster suicides. The underlying
assumption is that ‘suicidal behaviour may facilitate the occurrence of subsequent
suicidal behaviour, either directly (via contact or friendship with the index suicide)
or indirectly (via the media)’ (Haw et al., 2013). Those who are part of an at-risk
population and have geographical and psychosocial proximity to a suicide are
particularly vulnerable (Haw et al., 2013).

Methodological issues
Research has tended to focus either on descriptive reports, or on the statistical
verification of point and mass clusters. However, while both approaches have their
merits when taken in isolation, it is their combination that offers the best oppor-
tunity to further our understanding of the mechanisms of suicide clustering
(Arensman et al., 2013). Thus, in examining suicide clustering, it is important to
both verify the statistical significance of emerging clusters across space and time,
and also to examine the level of contagion (interrelatedness) of cases that occur
within clusters.
In recent years, research has moved beyond the exploratory stage and started
to systematically examine clustering patterns, using geospatial analysis, such as
SaTScan (Kulldorff, 1997). SaTScan has previously been used mainly to examine
clustering patterns in infectious diseases, and this technique offers an innovative
means of furthering our understanding of space-time (point) suicide clusters
(Bando et al., 2012; Cheung et al., 2012; Larkin and Beautrais, 2012). The use
of scan statistics allows us to statistically verify suicide clusters across both space
and time. The method tests whether the number of cases within any spatial/
temporal window exceeds the number expected by random process. Detection of
these types of clusters offers the potential to explore the factors underlying
clustering and will facilitate the implementation of intervention and post-
intervention strategies.
112 Ella Arensman and Carmel McAuliffe

Epidemiological aspects of suicide clustering

Taking into account that the perception of clustering itself can be a risk factor for
suicide, suicide clusters therefore differ from many other event clusters (Rezaeian,
2012). Most studies have reported on suicide clustering in adolescents and young
adults, and indicate that clusters account for 2–15 per cent of all teen suicides
(Insel and Gould, 2008). However, recent research has also identified clustering
of suicides among adults and older people, in particular, men (Arensman et al.,
2013; Chotai, 2005; Larkin and Beautrais, 2012). Generally, males are over-
represented among suicide clusters (Haw et al., 2013; Qi et al., 2012), but recent
studies show that females may represent up to 24 per cent of those involved in a
cluster (Jones et al., 2013). Recent studies investigating spatial and time-space
suicide clustering, found that suicide clustering was associated with lower socio-
economic status (Exeter and Boyle, 2007; Qi et al., 2012) and areas representing
a higher proportion of indigenous population (Hanssens, 2010; Qi et al., 2012).
Larkin and Beautrais (2012) investigated the prevalence of echo clusters in
New Zealand between 1990 and 2007. They identified nine distinct regions in
which echo clustering had occurred. The average time between initial suicide
clusters and echo clusters was 7.6 years with a range from 1.2 to 16.9 years.
In addition to geographical clusters, there is growing evidence showing time-
space suicide clusters among specific populations and settings, such as psychiatric
inpatients, adolescents and young adults in community settings (Haw et al.,
2013), schools (Poijula et al., 2001), and universities (MacKenzie, 2013). In a
recent study by Hawton et al. (2013), evidence was found for time-space
clustering of self-harm in prisons in England and Wales, in particular among
women and which was significantly associated with subsequent suicide.

The role of the media

There is evidence that suicide clustering and contagion are more prominent when
media coverage is extensive and when suicides are glamorized and reported upon
in detail (Niederkrotenthaler et al., 2012; Pirkis et al., 2006), with a stronger
impact on suicides that are similar to the respective model in terms of age group,
gender and suicide method (Niederkrotenthaler et al., 2009). In this regard,
Ladwig and colleagues (2012) found an 81 per cent increase in railway suicides
during a period of six weeks after the death of a well-known German football
goal-keeper who jumped in front of a train. Hegerl et al. (2012) looked at the
long-term effects, and identified an 18.8 per cent increase in railway suicides dur-
ing the two years after this event compared to the two years before. Regarding
the impact of the media, the authors concluded that media reports followed the
media guidelines to some extent, but it remains uncertain as to what the extent
of the increase in railway suicides might have been if the media had followed
the guidelines more thoroughly (Ladwig et al., 2012). Media reports covering
details of less well-known people, but elaborating on specific details of suicide
methods, such as carbon monoxide poisoning by burning barbecue charcoal and
inhaling hydrogen sulphide gas were also associated with significant increases
 Clustering and contagion of suicidal behaviour 113
in subsequent suicides and attempted suicides involving the same method
(Hagihara et al., 2013; Liu et al., 2007). A study on the impact of newspaper
reporting of hydrogen sulphide suicide on imitative suicide attempts in Japan
identified an immediate effect of media reports on subsequent suicide attempts.
The time lag between exposure to newspaper reports of suicide and suicide
attempts was one or three days, and the magnitude of the impact of front
page articles was greater than that of suicide articles in general (Hagihara et al.,
2013). A study by Jones et al. (2013) found that following statistical verification,
the size of a suicide cluster among young people in the Bridgend area of South
Wales, was smaller and shorter in duration than reported in the media. However,
most deaths in the suicide cluster occured after the media had started reporting
on initial cases of suicide.
There is growing evidence supporting the negative impact of new media on
suicide contagion and clustering. Information on specific suicide methods on
websites is associated with significant increases in suicides involving these
methods and suicide pacts among two or more people (Hitosugi, 2006; JijiPress,
2008; Lee et al., 2005; Rajagopal, 2004). A systematic review by Daine et al.
(2013) showed that internet use may exert both positive and negative effects on
young people at risk of self-harm or suicide. In terms of positive effects, young
people, who self-harm or are suicidal, commonly use the internet for seeking sup-
port and coping with difficulties. However, there is also evidence indicating that
the internet exerts a negative influence by normalising self-harm and potentially
discouraging disclosure or professional help-seeking (Daine et al., 2013).
Robertson et al. (2012) identified an association between suicide contagion
and clustering, and social networking and SMS text messaging. The cluster
involved eight young people aged 15–18 years in a city in New Zealand, and
which occurred over a six-month period. The young people attended different
schools and were living in different communities within the city, and most of
them were linked by social networking sites, including sites created in memory of
earlier suicide cases, text messaging and physical proximity. Seven of the eight
suicide cases were male, and mental health and relationship problems were present
in most of the cases. The study indicates that electronic communications increased
the risk of suicide contagion, and this also facilitated the rapid spread of informa-
tion and rumour throughout the community (Robertson et al., 2012).

Risk factors associated with suicide clustering

and contagion
In this section we try to address two separate but interrelated questions: First,
what are the characteristic risk factors among individuals involved in a cluster?
And, second, what makes an individual vulnerable to contagion?
The research evidence from narrative and statistical studies investigating point
clusters consistently focuses to adolescents and young adults as being most at risk
of suicide clustering (Bechtold, 1988; Davies and Wilkes, 1993; Gould et al.,
1990; Grigg, 1988; Johansson et al., 2006; Poijula et al., 2001; Tower, 1989;
114 Ella Arensman and Carmel McAuliffe
Ward and Fox, 1977; Wilkie et al., 1998; Wissow et al., 2001). While suicide
clustering is understood to be between two and four times more common among
young people aged 15–24 years than among other age groups (Gould et al.,
1990), it is nonetheless a rare phenomenon even among the young. In a study
investigating possible suicide clusters in Wales between 2000 and 2009 (Jones
et al., 2013), a temporo-spatial analysis only detected clustering when it was
restricted to the sub-group of deaths that occurred among 15–34-year-olds.
However, less than 1 per cent of possible suicide deaths among young people in
Wales during this time were identified as being cluster-related. Larkin and
Beautrais (2012) reported from their study investigating geospatial and temporal
distribution of suicides occurring in Canterbury province in New Zealand
between 1991 and 2008 that 1.1 per cent of teenage suicides over that time were
cluster-related. While cluster suicides were significantly younger than singleton
suicides (median age 29 and 37 years respectively), only one of the nine clusters
they identified was composed exclusively of young people aged 20 years or
younger. All eight remaining clusters included at least one individual aged 35
years or older. They argue that adult participation in cluster suicides is a neglected
area. Chotai (2005) compared suicide cluster cases with singleton cases in north-
ern Sweden and found that middle-aged and older males were most at risk,
although the author points out the low number of teenage suicides in the overall
sample. A report on suicides ascertained in the Cork region in Ireland between
August 2010 and June 2012 identified two point clusters using geospatial tech-
niques. The first cluster included 12 men and one woman with a median age of
47 years and an inter-quartile range (IQR) of 37.5 to 54 years. The second clus-
ter comprised three men and four women with a median age of 39 years and IQR
between 32 and 50 years (Arensman et al., 2013).
Suicide cluster deaths occur more frequently among males (Bechtold, 1988;
Chotai, 2005; Davies and Wilkes, 1993; Grigg, 1988; Ward and Fox, 1977;
Wissow et al., 2001). In one review of point clusters among adolescents
(Insel and Gould, 2008) females were identified as being at greater risk of
attempted suicide while males were at greater risk of completed suicide, consistent
with findings from studies of non-cluster suicidal behavior.
Individuals who die in suicide clusters tend to have high risk profiles
(Haw et al., 2013). Cluster victims are repeatedly described in the research
literature as vulnerable individuals (Davies and Wilkes, 1993; Larkin and Beautrais,
2012; Ward and Fox, 1977). For example, Larkin and Beautrais report from their
study of nine clusters that almost one-quarter (23.3 per cent) of all cluster cases
combined had a lifetime history of inpatient psychiatric admission, and
almost half (46.5 per cent) had a history of outpatient psychiatric care.
One-fifth (20.9 per cent) had a diagnosis of alcohol abuse or dependence with
almost one in four having a pattern of problem alcohol use in the year prior to
death. Drug problems in the year prior to death were reported for 14 per cent of
cases. Almost half (42 per cent) had a lifetime history of suicide attempt, and one
in five (18.6 per cent) had made at least one suicide attempt in the year prior to
death. More than half (51 per cent) had a lifetime history of threatening suicide
 Clustering and contagion of suicidal behaviour 115
and 40 per cent were known to have made a suicide threat in the year prior to
death. One in three cluster decedents (34.9 per cent) had attempted suicide in
the month prior to their death.
Despite this high prevalence of risk factors identified in descriptive studies
of suicide clusters, for example, drug and alcohol abuse, employment problems
and past history of self-harm, are common risk factors for suicide in general
and not unique to clustering (Haw et al., 2013). A fairly consistent trend in
the limited literature available is the lack of differences between cluster and
singleton suicides. Larkin and Beautrais (2012) found that cluster compared
to singleton suicides were similar on demographic characteristics including gen-
der, marital status, ethnicity, education and employment status. They found no
differences between singleton, cluster or index suicides on psychosocial or psychi-
atric characteristics including occurrence of stressful life events, presence of a
suicide note, physical health problems at the time of death, recent visit to a GP,
history of inpatient or outpatient psychiatric treatment, lifetime diagnosis of a
psychiatric illness, alcohol or drug use in the year prior to death, lifetime or past
year history of self-harm or suicide threat, or having a friend relative or partner
who had died by suicide. They did find, however, that clusters of suicides
were more likely to include people involved in suicide pacts (9.3 per cent vs.
0.9 per cent, p < 0.05). Compared to other cases in a cluster, index cases were
more likely to have financial problems at the time of their death (11.6 per cent vs.
33.3 per cent, p < 0.05).
A lack of methodologically sound studies has hampered our identification of
specific risk profiles among cluster suicides. In their review, Haw and colleagues
(2013) were only able to identify two case-control studies comparing suicide
cluster cases with singleton suicides (Chotai, 2005) or living controls (Davidson
et al., 1989). In both studies, other methodological limitations arose. For
example, in the study by Chotai (2005) only a limited range of possible risk
factors was examined (gender, age, marital status, area of residence, season of
birth and method of suicide); while in the study by Davidson and colleagues,
14 teenagers in two suicide clusters were compared with living controls (three
living controls for each suicide). Therefore, variables that characterized the
suicides could not be assumed to characterize cluster suicides specifically, as non-
cluster suicides were not included as a control group. In the study by Larkin and
Beautrais (2012), cluster suicides (n = 43) were compared with all non-cluster
suicides (n = 216) occurring in the region over the same time period. Although
the cluster cases were significantly younger than the singleton cases (median age
29 years compared with 37 years respectively), they were not matched by age and
gender. Despite their younger age, cluster cases had similar lifetime rates of
diagnosed psychiatric illness, inpatient psychiatric treatment and outpatient
psychiatric treatment; and similar proportions had a friend, relative or partner
who had died by suicide. Cluster cases had even higher rates of lifetime suicide
attempts and past year suicide attempts, although this was not significant. It is
possible that some of the differences between cluster and singleton suicides were
not detected as a result of inadequate power.
116 Ella Arensman and Carmel McAuliffe

Responding to suicide clusters and contagion

Early identification of emerging suicide clusters and contagion is crucial in order
to facilitate a strategic and co-ordinated response. It would be required to have
timely access to detailed information on the cases of suicide involved in order to
determine risk factors and interrelatedness among the suicide cases (Arensman
et al., 2013). In a number of countries, such as the US, Australia, New Zealand,
England and Wales, and Ireland, guidelines to respond to emerging suicide
clusters, have been developed and implemented. However, evaluations have not
yet been published.
A co-ordinated response involving relevant public health, health and
bereavement support services should be established in order to respond to the
needs of people affected, such as next of kin, friends, colleagues and people
affected in the community or setting (e.g. school, psychiatric ward) and to prevent
further suicidal behaviour (Askland et al., 2003; LIFE, 2012; Robertson et al.,
2012). Due to multiple losses in a short space of time, family members and friends
may experience complicated grief, which requires involving expertise in the area
of suicide bereavement support (Spiwak et al., 2012). Another key element of a
response plan is involving the media in order to ensure adherence to media
guidelines for suicide reporting and appropriate and balanced media reports.
Monitoring of social networking sites by suicide prevention agencies enables
access to conversations which may be related to possible subsequent suicides
(Robertson et al., 2012). In order to enhance responding to a suicide cluster
and to the needs of those who are affected and of the professionals involved, the
need for training should be explored and addressed, and crisis responses should
be linked to a long-term programme of suicide risk reduction and community
recovery (LIFE, 2012).

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Part II

Varied research evidence

and assessment perspectives
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9 Suicidal ideation and behavior
among sexual minority youth
Correlates, vulnerabilities, and
protective factors
Samantha Pflum, Kaitlin Venema,
Joseph Tomlins, Peter Goldblum
and Bruce Bongar

Compared to their heterosexual peers, sexual minority youth continue to

experience significant health disparities. These youth report differentially higher
rates of anxiety, depression, suicidality, low self-esteem, and substance use
(D’Augelli et al., 2002; Friedman et al., 2006; Poteat et al., 2009; Rivers and
Noret, 2008). Since 2001, the United States Surgeon General has identified sex-
ual minority youth as a ‘vulnerable population’ (Surgeon General, 2001). As a
result of environmental stressors such as peer bullying, family rejection, and
community-based victimization, sexual minority youth may be at particularly high
risk for suicide. Suicidal ideation, attempts, and completions are among the most
concerning disparities for this population (Poteat et al., 2011).
Rates of suicidal ideation and attempts vary based on sampling approaches,
definitions of constructs, geographical location, help-seeking, and other factors.
However, several decades of research have consistently demonstrated that
lesbian, gay, bisexual, and queer/questioning youth report higher levels of
suicidal ideation and attempts than heterosexual youth (Cochran and Mays,
2013; Goodenow et al., 2006; Mustanski et al., 2010; Russell and Joyner, 2001;
Russell and Toomey, 2012). Among sexual minorities, the odds of attempting
suicide are approximately two to seven times higher than the odds of suicide
attempt among heterosexuals (King et al., 2008; Haas et al., 2010). A Rhode
Island-based study demonstrated that 10 percent of sexual minority adolescents,
as compared to just over 3 percent of heterosexual teens, reported suicide attempts
severe enough to warrant medical attention (Jiang et al., 2010). The 2001
Massachusetts Youth Risk Behavior Survey reported a similar pattern, with
20 percent of LGB youth requiring medical attention after a suicide attempt,
as compared to 4.7 percent of heterosexual youth (Massachusetts Department
of Education, 2002). As a group, LGB youth experience greater levels of
suicidal ideation and behavior than their heterosexual peers (Suicide Prevention
Resource Center [SPRC], 2008). Sexual orientation itself does not lead to
suicidality among LGB youth; rather, environmental reactions to non-
heterosexual orientations increase suicide risk in this population (Savin-Williams
and Ream, 2003).
124 Samantha Pflum et al.

Suicide deaths among LGB youth

Cross-sectional research suggests that sexual minority youth are ‘far more likely’
to commit suicide than their heterosexual peers (Hershberger and D’Augelli,
1995; Plöderl et al., 2013). However, completed suicides among this population
have not been thoroughly documented or examined empirically. Less is known
about completed suicides due to lack of data on sexual minority individuals
in probability studies, as well as the difficulty in determining sexual orientation
postmortem (Cochran and Mays, 2013). Sexual orientation is rarely assessed
in psychological autopsy studies, which involve the reconstruction of suicidal
deaths through interviews with survivors (Copeland, 1993). Youth may not be
‘out’ to loved ones or may be unsure of their sexual identity, further confounding
the accurate measurement of suicide completions among LGB youth. Additionally,
studies of completed suicides among heterosexuals and sexual minorities have
been flawed by the use of non-representative samples, such as incarcerated indi-
viduals and psychiatric patients (McDaniel et al., 2001). When information on
sexual orientation is collected, data on completed suicides tends to drastically
exaggerate or minimize the rate of completed suicides among sexual minorities
(SPRC, 2008).
Although definitive data on suicide rates for LGB youth are lacking, extant
research indicates that the most reliable predictors of suicide risk among both
heterosexuals and sexual minorities are suicidal ideation and prior suicide attempts
(SPRC, 2008). Based on the higher rate of suicide attempts among LGB youth
and the seriousness of their suicide attempts, it is likely that LGB youth experi-
ence higher rates of suicide deaths than their heterosexual peers (SPRC, 2008).
Some research indicates that sexual minority youth have more risk factors and
fewer protective factors than their heterosexual peers, placing them at higher risk
for suicidal behavior and completions (SPRC, 2008). LGB youth who are home-
less, living in foster care, and/or involved in the juvenile justice system are at even
higher risk for suicide attempts and completions than their LGB peers who do not
endorse these risk factors (SPRC, 2008).

The etiology of increased suicide risk among LGB youth

Sexual minority stress

The minority stress model (Meyer, 2003) helps to elucidate some of the
connections between sexual minority identity and suicidality. In most industrial-
ized societies, individuals identifying as lesbian, gay, or bisexual are part of a
stigmatized and devalued cultural group. This disadvantaged social position
leads to the experience of minority stress (Meyer, 2003). For LGB individuals,
‘stigma, prejudice, and discrimination create a hostile and stressful social
environment that causes mental health problems’ (Meyer, 2003, p. 674). These
widespread experiences of stigma negatively impact self-perception and increase
the expectation of social rejection (Hatzenbuehler, 2009; Meyer, 2003).
 Suicidal ideation and behavior 125
Eventually, the elevated level of social adversity contributes to higher psychiatric
morbidity (Hatzenbuehler, 2009; Meyer, 2003).
Sexual minorities consistently report more everyday experiences of dis-
crimination; perceptions of discrimination are closely linked to mental health
morbidity among lesbian, gay, and bisexual individuals (Almeida et al., 2009;
Cochran and Mays, 2007; Herek, 2009; Mays and Cochran, 2001). Moreover,
stress associated with the awareness, discovery, and disclosure of one’s LGB
identity is a unique risk factor for sexual minority youth. LGB youth are at
greater risk for suicide attempts if they ‘come out’ to others at an earlier age
(Remafedi et al., 1991). Particularly for youth, stigma-based experiences that
appear ‘minor’ can build up over time, resulting in serious mental health
consequences (Meyer et al., 2011). Micro-aggressions, brief ignominies that
communicate derogation towards LGB individuals, can lead to or exacerbate
mental health issues (Nadal, 2008; Sue et al., 2007). These can take the form of
heterosexist terminology, use of derogatory terms, and the assumption of a
universal heterosexual experience (Nadal, 2008). As a result of continued expo-
sure to stressful events – however small – sexual minorities may experience more
adverse mental health outcomes than their heterosexual peers (Meyer, 2003).

The psychological mediation framework

Based on findings from the minority stress framework, psychiatric epidemiology,
and general psychological processes related to morbidity, Hatzenbuehler (2009)
put forth a psychological mediation framework to elucidate the etiology of
mental health disparities among sexual minorities. This framework posits that,
through experiences of stigma-induced stress, sexual minorities become more
vulnerable to psychological processes that contribute to psychopathology in
heterosexual individuals (Hatzenbuehler, 2009). Relative to heterosexuals, the
experience of stigma-related stress causes increases in emotional dysregulation,
social difficulties, and cognitive processes influencing risk for psychopathology
(Hatzenbuehler, 2009). By taking both unique and general stressors into
account, this framework provides a more advanced understanding of influences
upon mental health disparities in the LGB population.

Correlates of suicidality among sexual minority youth

Ecological systems theory (Bronfenbrenner, 1979) can be used as a framework to
explore the components of elevated risk, correlates of suicidality, and relevant
protective factors for LGB youth. Correlates of suicidality can be found at many
ecological levels ranging from the immediate microsystem (e.g., family,
peers, school) to the macrosystem (e.g., general societal and cultural norms)
(Bronfenbrenner, 1979). Among LGB youth, suicide attempters have been found
to experience higher levels of both general stress and stress related to their sexual
minority identities (Savin-Williams and Ream, 2003). Such stressors can be local-
ized in various socio-ecological levels, such as individual vulnerability to mental
126 Samantha Pflum et al.
health problems, conflict with rejecting family members, and intolerant social
environments.

Depression: prevalence and etiology

Compared to their heterosexual counterparts, sexual minority youth are at
increased risk for both internalizing and externalizing symptoms (Hatzenbuehler,
2009). Major depressive disorder is the most commonly experienced mental
health condition among sexual minorities, including both youth and adults
(Cochran and Mays, 2013). Approximately 20 percent of sexual minorities expe-
rience significant depressive symptoms on an annual basis, and sexual minorities
are twice as likely than heterosexuals to suffer from depression (Cochran and
Mays, 2013; Hatzenbuehler et al., 2010). Given its close association with
suicidality, depression will be the focus of this section.
Interpersonal theories of depression posit that stressors, particularly those
related to stigma, alter interpersonal relationships and render individuals more
vulnerable to psychopathology (Hatzenbuehler, 2009). For sexual minorities,
stigma-related stress may lead to isolation, internalized homophobia, and as a
consequence, diminished social support (Hatzenbuehler, 2009; Link et al.,
1997). Concerns about rejection and negative evaluation may cause sexual
minorities to avoid close relationships for fear of others discovering their
stigmatized identities (Pachankis, 2008). Although this avoidance enables the
temporary escape from rejection, identity concealment may lead to greater
loneliness, isolation, and social anxiety (Pachankis, 2008).
Social isolation has been linked to greater psychological distress, particularly
symptoms of depression and anxiety (Hatzenbuehler, 2009). Additionally, the
chronicity of stressors faced by sexual minorities often engenders hopelessness, a
construct that is associated with both depression and suicidality (Russell and
Joyner, 2001). Chronic exposure to discrimination, rejection, and interpersonal
victimization can lead to negative self-schemas and internalized homophobia, in
which negative societal views of homosexuality are turned against the self.
Cross-sectional research has demonstrated that LGB individuals have lower
self-esteem than heterosexual individuals, a construct that has been linked to
stigma-related stressors (Plöderl and Fartacek, 2005). In turn, negative self-
esteem is predictive of suicidality (Savin-Williams and Ream, 2003).

Peer victimization
Victimization based on known or suspected sexual minority identity is the most
common form of bias-related violence (Pilkington and D’Augelli, 1995; Herek,
1989). Negative outcomes of such victimization include disruptions of the
coming out process, increased internalized homophobia, decreases in self-esteem
and self-worth, heightened fears for personal safety, and exacerbations of mental
health symptoms (Pilkington and D’Augelli, 1995). As a result of societal
stressors and prejudices, sexual minority youth are particularly vulnerable to
 Suicidal ideation and behavior 127
mental health problems, a vulnerability that can be exacerbated by victimization
(Hershberger and D’Augelli, 1995).
For sexual minority youth, there is a strong correlation between discrimination,
victimization, and increased self-harm, suicidal ideation, and suicide attempts
(Goldblum et al., 2012; Hershberger and D’Augelli, 1995; Poteat et al., 2011).
Compared to victimization that is not bias-based, victimization based on sexual
minority status (homophobic victimization) is associated with significantly higher
levels of both suicidal ideation and attempts (Russell et al., 2012). Although these
results have been based primarily on cross-sectional studies, recent longitudinal
findings offer prospective evidence of this relationship. Among diverse sexual
minority youth, early reports of victimization predicted future suicidal ideation
and deliberate self-harm (Liu and Mustanski, 2012). After suicide attempt
history, victimization based on sexual minority status was the strongest predictor
of self-harm (Liu and Mustanski, 2012).
School climate and overall school safety are strongly connected to the experi-
ence of peer victimization among LGB youth. The Gay, Lesbian, and Straight
Education Network (GLSEN) revealed that 84.9 percent of LGB students in
elementary, middle, and high schools heard homophobic remarks from peers,
teachers, and school staff (Kosciw et al., 2012). Additionally, 63.5 percent of
sexual minority students felt unsafe and unwelcome at school, and 81.9 percent
were verbally harassed because of their sexual orientation (Kosciw et al., 2012).
Homophobic victimization has been shown to predict suicidality, depression,
substance use, and school problems among sexual minority youth (Birkett
et al., 2009; Poteat et al., 2011). Students who experienced high levels of
victimization based on sexual orientation endorsed higher levels of depression
and lower levels of self-esteem (Kosciw et al., 2012). Even in the absence of
direct homophobic victimization, youth may experience increased anxiety,
depression, and isolation in schools with pervasive use of anti-gay language
(Birkett et al., 2009). Feeling unsafe and unwelcome in school is associated with
heightened levels of suicidal ideation and suicide attempts (Poteat et al., 2011);
such experiences may also be connected to a sense of thwarted belongingness,
a primary component of the interpersonal theory of suicide (Joiner, 2010).
Serious suicide attempts requiring medical attention are more common among
sexual minority youth attending schools perceived as safe for most youth
(Goodenow et al., 2006). Thus, overall ratings of school safety may not be
representative of the experiences of LGB youth. While heterosexual students
thrive in such schools, LGB students may suffer significantly.

Family relationships
For sexual minority youth, families may not be sources of solace from external
prejudice and victimization. Many fear coming out to their families, noting that
the prospect of such disclosure is ‘extremely troubling’ (Hershberger and
D’Augelli, 1995, p. 65). LGB youth report rejection, harassment, and abuse from
immediate family members, and are more likely to experience long-term parental
128 Samantha Pflum et al.
maltreatment (Corliss et al., 2001; Pilkington and D’Augelli, 1995). LGB
children may be more likely to experience maltreatment by their parents in fam-
ilies with multiple siblings (Balsam et al., 2005). Ryan and colleagues (2009)
demonstrated that LGB young adults who noted higher levels of family rejection
during adolescence were 8.4 times more likely to report having attempted suicide,
5.9 times more likely to report high levels of depression, 3.4 times more likely to
report illegal drug use, and 3.4 times more likely to report having engaged in
unprotected sexual activity (compared to peers from families with low or moder-
ate levels of rejection). LGB youth from families with low or moderate levels of
rejection were found to be at significantly lower risk for these negative mental
health outcomes (Ryan et al., 2009). Such findings have important implications
for understanding the etiology of psychiatric symptoms, particularly suicidality,
among sexual minorities. Although such research has not definitively established
causality, it has indicated a strong and significant link between parental rejection
and negative mental health outcomes in LGB youth (Ryan et al., 2009).

Protective factors
In examining health disparities between sexual minority and heterosexual
youth, it is apparent that some of these disparities may be due to lower levels of
protective factors among sexual minority youth (Saewyc, 2011). When present,
these factors can help to mitigate risk and to support positive development for
LGB youth (Saewyc, 2011). As members of a stigmatized group, sexual minority
youth can develop a variety of coping strategies and support systems to minimize
the negative psychological consequences of societal bias.

Family support
A supportive home environment can be crucial for decreasing suicide risk among
sexual minority youth. For LGB adolescents, family acceptance and support are
associated with positive health outcomes in young adulthood, including self-
esteem, social support, and general health (Hershberger and D’Augelli, 1995;
Poteat et al., 2011; Ryan et al., 2010). Family support helps to protect against
negative health outcomes, including depression, substance abuse, suicidal
ideation, and suicide attempts (Poteat et al., 2011; Ryan et al., 2010; SPRC,
2008). Such support may be capable of attenuating the effects of sexual
orientation-based victimization (Poteat et al., 2011). In regards to the long-term
effects of homophobic bullying, adults who recalled having positive friendships
and strong family or community relationships during adolescence reported
greater resilience and positive mental health outcomes later in life (Rivers, 2011).
Parents are capable of promoting the overall health of sexual minority youth by
providing both general support and sexual orientation-specific support (such as
affirming their child’s LGB identity) (Poteat et al., 2011). Specific suggestions for
parental promotion of health can be found in the Recommendations section of
this chapter.
 Suicidal ideation and behavior 129

School-based protective factors

School-based support can promote positive mental health outcomes for LGB
youth. Feelings of safety and connectedness at school are associated with lower
levels of suicide attempts (Saewyc, 2011). Several studies have explored the role
of Gay-Straight Alliances (GSAs) in relation to mental health outcomes among
LGB youth. Findings indicate that sexual minority youth attending schools with
GSAs report more positive health and academic outcomes than youth in schools
without GSAs, including lower rates of suicide attempts (Birkett et al., 2009;
Goodenow et al., 2006; Poteat et al., 2013; Saewyc, 2011).
GSAs may function to reduce suicidality by decreasing the victimization that
has been linked to suicidal ideation and attempts (Goodenow et al., 2006).
Schools that promote student diversity, have LGBT-inclusive curricula, and have
anti-bullying policies that specify the protection of sexual minorities have been
shown to reduce high-risk behaviors among sexual minority students (Goodenow
et al., 2006). Inclusive anti-bullying policies have a strong negative association
with suicide attempts, even when victimization and social support are taken into
account (Goodenow et al., 2006).

Health professionals
Health professionals also play a role in supporting the acceptance of sexual
minority youth within families (Ryan et al., 2010). The Family Acceptance
Project (FAP) is a San Francisco-based research and intervention program
designed to assess and improve parental support for sexual minority children
(Ryan et al., 2010). Mental health and medical providers can help families identify
supportive behaviors that can protect against risk and promote healthy psycho-
logical development. Such behaviors include talking with children about their
LGBT identity, advocating for youth when they are mistreated due to their
sexual minority identity, and connecting an LGBT child to an LGBT adult role
model (Ryan et al., 2010). As family acceptance is associated with reduced odds
of suicidal ideation and attempts, it can be crucial for health professionals to
facilitate positive family reactions to a youth’s ‘coming out’ process (Ryan et al.,
2010). Educating families of sexual minority youth about the serious negative
health impact of family rejection (including depression, suicidality, and substance
use) can mitigate risk and help improve health outcomes in LGB youth (Ryan
et al., 2010).
For LGB students who are bullied at school or are rejected by their parents,
psychologists, counselors, and nurses often serve as first responders. Rates of
suicidality among LGB youth have been shown to decrease in schools that offer
supportive nonacademic counseling (Goodenow et al., 2006). Mental health and
medical professionals can provide a safe space for students to disclose their
concerns, but must first signal to youth that they are open to diversity in sexual
orientation and relationships. After ‘passing the test’, professionals may experience
increased disclosure of information related to being LGB and increased willingness
to discuss concerns related to sexual minority status (Weiss, 1994). Without
130 Samantha Pflum et al.
education and training on LGB-specific issues, health professionals may not have
the competencies required to address difficulties that are unique to sexual
minorities (American Psychological Association, 2012).

Recommendations
Based on the information on suicidal ideation and behavior among LGB youth
presented in this chapter, we provide a number of recommendations intended to
maximize protective factors among LGB youth.

For mental health and medical professionals

• Seek further training on sexual minority-specific issues in order to facilitate
continued professional development. Specific guidelines for working with
this population can be derived from the American Psychological Association’s
Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients
(2012).
• When LGB youth present with symptoms of depression and/or suicidality,
conduct a thorough assessment of risk and protective factors. A lack of
protective factors has been linked to suicidality, making it essential to
capitalize on young clients’ existing strengths and healthy coping skills.
• Identify local LGB support programs and online resources to educate parents
about how to support their LGB children.
• Build a network of referrals that specialize in providing clinical, educational,
and support services for LGB youth.
• Speak with LGB adolescents about family reactions to their sexual identity.
For families who have trouble accepting their child’s sexual identity, refer to
LGB community support programs and for supportive counseling.
• Advise parents that negative reactions to their child’s LGB identity negatively
influences their child’s mental health. More information on this research can be
found through the Family Acceptance Project (www.familyproject.sfsu.edu).

For teachers and school administrators

• Implement and support policies and procedures to prevent harassment due
to LGB identity. Ensure that sexual orientation and gender identity are
explicitly included in nondiscrimination and anti-bullying policies.
• Provide education about LGB issues to students, administrators, staff, and
teachers to increase safety in schools. Encourage the implementation of
LGB-inclusive curricula.
• Support the establishment and maintenance of a Gay-Straight Alliance (GSA)
to facilitate social support and decrease bullying and suicidality among LGB
students. Encourage teachers and school staff to place LGBTQ-affirmative
stickers (e.g., Human Rights Campaign, Trevor Project) on their doors to
signal openness and safety.
 Suicidal ideation and behavior 131
• Regularly monitor classrooms, hallways, and cafeterias for the presence
of anti-gay comments. Seek support from your local chapter of GLSEN
(www.glsen.org) if you witness homophobic victimization.

For parents and families

• Be attuned to signs that a child may be experiencing symptoms of
depression and/or thoughts of suicide (hopelessness, withdrawal, school
failure, talking about ‘not wanting to be here’, etc). Seek support from a
mental health professional if any of these signs are noted.
• A supportive home environment is crucial for attenuating suicidality
among LGB youth. Express affection, validation, and support related to all
aspects of your child’s identity, particularly their sexual minority identity.
• Advocate for your child whenever he or she faces peer victimization. Engage
with organizations that support families of LGB youth, such as Parents and
Friends of Lesbians and Gays (PFLAG). If it is difficult to accept your child’s
LGB identity, consider seeking support from an organization such as the
Family Acceptance Project (www.familyproject.sfsu.edu).

Conclusion and future directions

Contemporary research underscores the importance of understanding the
diverse experiences of LGB youth. Family relationships, peer victimization,
and mental health concerns are risk factors that are particularly salient for this
population. Fostering safe and supportive environments for LGB youth, both in
school and at home, is essential to decreasing suicidal ideation and behavior. The
development of Gay-Straight Alliances, implementation of LGB-inclusive school
criteria, and facilitation of parental openness to sexual minority identities can
minimize risk and bolster protective factors. LGB suicide prevention should
target families, peers, and schools, and should incorporate health professionals in
prevention efforts.
More research is needed to identify rates of completed suicide among LGB
youth, a development that will aid in the promotion of specific protective factors
and prevention efforts for this population (McDaniel et al., 2001). Future
research, particularly large-scale epidemiological studies, would benefit from the
inclusion of diverse sexual orientation and gender identity variables (SPRC,
2008). Incorporating questions related to discrimination, peer victimization, and
mental health problems can also improve understanding of the factors associated
with suicidality among LGB youth. The recommendations and suggestions for
future research included in this chapter aim to reduce mental health disparities
between LGB and heterosexual youth. Importantly, such recommendations
intend to promote the health, safety, and validation of LGB youth as valuable,
emboldened members of our communities.
132 Samantha Pflum et al.

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10 Spatial and temporal
distribution of suicidal
behaviour with a special
focus on Hungary
Understanding the variations
Zoltán Rihmer, Xenia Gonda
and Peter Dome

Suicidal behaviour (suicidal ideations, attempts and completed suicides) is a

major public health problem everywhere in the world, and its prediction and
prevention are receiving increasing attention. About 1 million people commit
completed suicide in the world every year and the global suicide rate is 14 suicides
per 100,000 inhabitants: more specifically 18 suicides per 100,000 males and
11 suicides per 100,000 females (Levi et al., 2003; WHO). Suicide attempts are
more prevalent, approximately 3–5 per cent of the adult population have made at
least one attempt during his/her lifetime. Attempts are three times more frequent
among youths than among people above 30 years of age (Pompili et al., 2008;
Goldman-Mellor et al., 2013) In spite of the fact that suicide rates of different
countries and continents differ substantially, the rate of completed suicide, in
general, is much higher among psychiatric patients, among males, among
older people and among Caucasians and among those who have made at least one
suicide attempt.
A history of untreated major psychiatric (particularly depressive and alcohol-
related) disorders constitutes the most important risk factors for both
completed and attempted suicide. However, several environmental, psycho-
social and personality factors (given periods of the calendar year, adverse
childhood events, psycho-social stressors, financial problems, unemployment,
impulsivity, affective temperaments carrying a depressive component, etc.) and
other forms of addictive behaviours than drinking (e.g. cigarette smoking)
have been also found to be in a statistically significant positive relationship with
suicide mortality (Isacsson, 2000; Rihmer et al., 2002, 2007; Rihmer, 2007; Sher,
2006; Almasi et al., 2009; Dome et al., 2010b, 2011; Vázquez and Gonda,
2013). It follows from the above that suicide events are not expected to be homo-
geneously distributed either in space and in time or in different demographic,
social and health-related subpopulations. This fact can lead to the identification
of several clinically explorable suicide risk factors and the ability to plan effective
preventive strategies.
 Distribution of suicidal behaviour 137

Distribution of suicide in space and time – geographic

and seasonal variations
In the last decade the highest annual suicide rates were reported from Eastern
Europe (13–42 suicides per 100,000 persons), some countries (e.g. Japan
and the Republic of Korea) of the Western Pacific Region and also from Sri Lanka
(with rates higher than 20 suicides/100,000/year) followed by Western/
Nordic European countries (8–21 suicides per 100,000 persons) and North
America and Australia/New Zealand (11–13 suicides per 100,000 persons). Latin
America as well as ‘Latin Europe’ (Greece, Spain, Italy), Israel and Central Asian
countries report annual suicide rates less than 10 (Wasserman, 2000; Levi et al.,
2003; Rihmer and Akiskal, 2006). Spatial differences in European suicide rates
have been more or less stable over the last 200 years (Kandrychyn, 2004). It is
worthy to note that – in general – immigrants have higher suicide rates than
their hosts and also that the rates among immigrants tend to follow those
of the country of origin, showing a significant positive correlation between the
two rates (Ratkowska and De Leo, 2013; Bursztein Lipsicas et al., 2012).
Reasons for these great differences between national/regional suicide rates
have not been fully explained. Geographic (latitude, longitude, altitude), climatic,
dietary, religious, socio-cultural and economic differences can be taken into
account, but differences in the psychiatric morbidity, as well as the accuracy of the
registration of suicide, the stigma associated with suicide possibly influencing
reporting rates, the availability of lethal methods, and the availability of the
social/health care systems should also be considered (Rihmer et al., 1993, 2002;
Lester, 1995; Preti, 2002; Tondo et al., 2006; Voracek and Tran, 2007; Stuckler
et al., 2011). Kapusta et al. (2011) recently reported that different rates of autopsy
between countries and longitudinal changes in the autopsy rate within the same
country may also influence official suicide statistics (Kapusta et al., 2011).
It has been repeatedly shown that suicide rates are higher in higher latitudes
(with lower levels of illumination) both in the Northern and the Southern
Hemispheres (Lester, 1970; Heerlein et al., 2006). In addition, a significant
relationship between suicide mortality and longitude has been also reported;
suicide rate is significantly higher in the Western than in the Eastern regions of
the United States (Lester, 1986; Haws et al., 2009) and also higher in Eastern
Europe compared to Western Europe (Wasserman, 2000; Levi et al., 2003;
Rihmer and Akiskal, 2006). However, analysing the data from 2584 US counties,
recent studies showed that after controlling for the percentage of old people, the
percentage of males, the percentage of white, median household income, and
population density of each county, the higher-altitude counties had significantly
higher suicide rates than the lower-altitude counties (Haws et al., 2009; Brenner
et al., 2011). Similar findings have recently been reported from Austria (Helbich
et al., 2013). The positive relationship between altitude and suicide mortality can
explain some geographic differences, like the Western-Eastern differences in the
United States, as higher mountains are situated primarily in the Western part of
that country. One group of authors speculated that decreased oxygen saturation
138 Zoltán Rihmer et al.
at high altitude may exacerbate the bio-energetic dysfunction associated with
affective illness and suicide (Haws et al., 2009). However, the picture is much
more complicated, because it has been also found that the lithium level in drinking
water – that shows a significant negative correlation with the suicide rate in several
countries (Blüml et al., 2013; Sugawara et al., 2013) – is significantly lower at
higher altitudes (Helbich et al., 2013). In addition, according to the results of a
study of the US residents of higher and lower dwelling places, they differed from
each other in several sociodemographic factors, proportion of handgun ownership,
access to mental health services, etc., and these differences may be at least partially
responsible for the differences in suicide rates of places situated on high vs. low
altitudes (Betz et al., 2011).
Moreover, dietary tryptophan intake – a precursor of serotonin – also shows a
significant negative correlation with national suicide mortality (Voracek and Tran,
2007), and our most recent preliminary findings suggest a positive correlation
between the level of arsenic in drinking water and the suicide rate in Hungary
(Rihmer et al., unpublished). Considering all the above it is evident that the
suicide mortality of a given region is the result of the very complex interplay of
several geographic/climatic/dietary, as well as other (psychiatric, economic and
cultural) factors.
Suicide rates are high in large parts of Northern and Eastern Europe and some
of the highest figures have been reported in Hungary (Levi et al., 2003; Rihmer
and Akiskal, 2006). In addition to psycho-social factors, several lines of evidence
indicate genetic and biological contributions to the unexpectedly high Hungarian
suicide rate (Voracek et al., 2007a; Voracek and Tran, 2007). Within Europe the
countries with the highest suicide rates constitute a contiguous J-shaped belt
from Finland through the Baltic countries, Russia, Belarus and Ukraine to central
Europe (Hungary, Slovenia, Austria) (Voracek et al., 2007a). Genetic similarities
observed between populations of these countries led to the Finno-Ugrian
Suicide Hypothesis which states that high suicide rates of these countries are the
consequence of a shared genetic susceptibility (Voracek et al., 2007a). The genetic
background of this phenomenon is very probable because other (e.g. cultural/
socio-political/economic) features of these countries are quite different.
Consonant with the theory about the genetic background of the high suicide rate
of Hungary, Hungarian immigrants in the United States of America have
the highest suicide rates of all immigrant groups (Lester, 1995). In addition, the
existence of an unfortunate genetic/cultural susceptibility of Hungarians to sui-
cidal behaviour is further bolstered by the fact that suicide rates of those Romanian
counties where the proportion of Hungarian people is high (e.g. Harghita,
Covasna, Mures) were much higher than of those counties where the population
percentages of Hungarians are low (Voracek et al., 2007b). The possible causes
of different national/regional suicide rates are listed in Table 10.1.
Between 1960 and 2000 in the vast majority of years the suicide rate of
Hungary was the highest in the world. The reason for this very high suicide mor-
tality of Hungary is not fully understood. One possibility is that the medical
examiners in Hungary certify those deaths as suicide which would otherwise be
 Distribution of suicidal behaviour 139

Table 10.1 Possible causes of different national/regional suicide rates (after Rihmer
et al., 2002)

• Geographic/climatic differences (sunlight, temperature, latitude, longitude,

elevation, lithium in the drinking water)
• Socio-cultural differences (alcohol/drugs, religion, alimentation, living place, family
structure, media)
• Economic differences (unemployment, availability/quality of social and healthcare,
living standard)
• Differences in availability of lethal methods (domestic/car exhaust gas, guns,
toxicity of medicines)
• Differences in psychiatric morbidity (depression, substance use disorders)
• Differences in the accuracy of the registration of suicide
• Political situation (war/civil war)

labelled as undetermined death or as death related to other causes. However, the

highest suicide rate of Hungarian immigrants in the United States (Lester, 1995)
and the similarly high suicide rate of ethnic Hungarians living in Romania
(Voracek et al., 2007b) contradict this possibility. Political or economic causes are
also very unlikely, as between 1960 and 1990 the suicide rates of Poland, Bulgaria,
Romania, and former Yugoslavia (countries with similar political and economic
systems) were around one-third of the Hungarian figure and during the
mentioned period, in the majority of the years, the suicide mortality of Denmark,
Finland, Austria, Switzerland and Sweden (with much more advantageous politi-
cal and economic situations) have been among the top ten in the world. As
mentioned above, the most established risk factor(s) of suicide are different forms
of (untreated) major affective disorders. Although direct comparison of national
epidemiological data on the prevalence of affective disorders is not possible due
to some methodological issues (e.g. different studies have frequently used
different diagnostic instruments), it can be said that the lifetime prevalence of
‘any’ bipolar disorder, which carries the highest risk of suicide (Rihmer et al.,
1990b; Szadoczky et al., 2000; Rihmer, 2005), is unusually high in Hungary
(5.1 per cent) (Pini et al., 2005; Szadoczky et al., 1998). Albeit the lifetime
prevalence of major depressive disorder according to DSM-IV criteria in the
Hungarian population (15.1 per cent) is similar to corresponding data from other
European countries and the USA, a recent study – assessing depressive symptoms
using CES-D in the general population of 23 European countries – reported the
highest mean scores in Hungary among all the investigated countries (Hasin et
al., 2005; Van Velde et al., 2010). In summary, these results raise the possibility
that the high prevalence of affective (especially bipolar) disorders (and possibly
also the threshold and sub-threshold manifestations of bipolarity and bipolar
spectrum disorders) in the Hungarian population may be one of the most impor-
tant contributors to the markedly high suicide rate of Hungary.
Several epidemiological studies have suggested that the numerical distribution
of suicide cases is uneven during the calendar year (Christodoulou et al., 2012).
According to the highly replicated results there is a peak in the number of suicide
140 Zoltán Rihmer et al.
cases in the spring and early summer (and – in some studies – a smaller peak in
autumn for females), and a trough in the winter. In general, violent suicide cases
(typical for males) are mainly responsible for the seasonal inequality of suicide
rates and the seasonality of suicides is more pronounced at higher latitudes and in
rural areas (Heerlein et al., 2006; Christodoulou et al., 2012). Studies show that
this is the typical seasonal incidence of suicide mortality and is mainly the
consequence of the seasonal incidence of depression-related suicides (Reutfors et
al., 2009; Postolache et al., 2010). The peak of suicide mortality relates to the
rapid increase of environmental light in spring and the number of suicides,
particularly violent suicides increase parallel to the duration of daily sunshine
(Rocchi et al., 2007). The seasonal variation of suicide also corresponds well to
the annual fluctuation of some indices of the central serotonergic metabolism,
including brain serotonin transporter binding capacity, indicating significantly
lower brain serotonergic activity in spring and summer (Praschak-Rieder et al.,
2008). Other links between light exposure and elements of the serotonergic
system (e.g. 5-HT1A receptor) were revealed recently (Spindelegger et al., 2012).
The majority of longitudinal investigations have provided some evidence that
seasonality in suicidal behaviour has decreased in several countries in the recent
decades (Voracek et al., 2004; Mergl et al., 2010; Sebestyen et al., 2010), but
some studies from other countries have found either increasing or unchanging
trends in suicide seasonality (Christodoulou et al., 2012). As the seasonality of
suicide is mostly the reflection of the seasonality of depression-related suicides,
some studies suggest that the decreasing seasonality of suicide mortality could be
a good marker of the lowering rate of depression-related suicide cases in the
population, particularly among males (Rihmer et al., 1998; Mergl et al., 2010;
Sebestyen et al., 2010).
Although several investigations aimed to disclose the diurnal pattern of suicidal
behaviour, they have been unable to demonstrate a clear and universal pattern
as yet (Zakharov et al., 2013; Erazo et al., 2004; Preti and Miotto, 2001; Doganay
et al., 2003).
The relatively few studies that have investigated the association between ‘season
of birth’ and the risks of suicidal and other violent behaviours provided somewhat
inconclusive results (Dome et al., 2010a).

Geographic and temporal variation of suicide in Hungary

Regional variation and urban–rural differences

Similarly to some other countries, marked regional differences in suicide rates are
present in Hungary: the suicide rates are higher in the south-eastern than in the
north-western parts of the country (Neeleman et al., 1998; Rihmer et al., 1990a;
Zonda et al., 2010; Rihmer et al., 2013a). This pattern is quite stable in time (the
first mention of this phenomenon was in the year 1864) (Rihmer et al., 1990a;
Zonda et al., 2010; Buda, 2001). Intriguingly, some results suggest that those
subjects who were born in Hungarian areas with high-suicide rates have a higher
 Distribution of suicidal behaviour 141
chance of committing suicide after relocating to other regions from their place of
birth (Moksony, 2003; Zonda et al., 2010). Although some possible explanations
of the spatial inequality of suicide rates have been proposed (e.g. the proportion
of Protestants is higher in the south-eastern region; there are regional differences
in the reported rates of depression; there are also differences in attitudes towards
suicide and levels of social integration in the Durkheimian sense between popula-
tions with high vs. low suicide rates), but the exact explanations are still missing
(Bálint, 2008; Rihmer et al., 1990a; Zonda et al., 2010). The only study that tried
to explore the cause(s) of the marked regional differences in suicide mortality in
Hungary based on exact data found a significant negative correlation between the
suicide rates and the rates of treated depressions in 19 counties of Hungary; the
higher the rate of recognized (treated) depression, the lower the suicide rate in
the given county (Rihmer et al., 1990a). However, this cannot be a full explana-
tion, because the mentioned regional difference in suicide mortality of Hungary
has been present from the beginning of the twentieth century, several decades
before the introduction of antidepressants. However, looking at the severity of
depressive symptoms, as measured by the Beck Depression Inventory, in the rep-
resentative sample of Hungary, it was found that the highest mean total Beck
scores were found in North-East Hungary, where the suicide rate was also among
the highest (Kopp et al., 1995; Székely and Purebl, 2007).
Although ‘urban–rural’ differences in suicide rates were negligible in the
1970s, a growing gap between urban and rural suicide rates is observable on the
long run in Hungary. Accordingly, a clear trend evolved up to 2010: the greater
the level of urbanicity, the lower the level of suicide rate (Rihmer et al., 2013a).
This phenomenon is in accordance with observations from several other countries
(Kapusta et al., 2008). In females there was an obvious association between domi-
cile and suicide rate in all years examined (1970, 1980, 2010): suicide rates were
higher for those females who lived in urban than for those who lived in rural
regions (but to the end of the observation period the difference had almost
entirely dissipated). A diametrically opposite trend may be observed among males.
Very similar results were reported from nearby Austria regarding the same period
(Kapusta et al., 2008). Investigating the distribution of suicide mortality
across the 175 micro-regions of Hungary between 2005 and 2011, age- and
gender-standardized mortality ratios for suicide were significantly associated with
the ‘political integration’ variable (measured by election participation rates) in a
negative and with ‘lack of religious integration’ and ‘disability pensionery’ vari-
ables in a positive manner. These results may draw attention to the relevance and
abiding validity of the classic Durkheimian suicide risk factors – such as lack of
social integration, a correlate of some mental disorders – with regard to the spatial
pattern of Hungarian suicides (Bálint et al., 2013).

Seasonal/circaseptan fluctuation and ‘season of birth’ effects

Regarding the seasonality of suicide mortality, the Hungarian data are in line with
the above-mentioned results from other countries (Rihmer et al., 2013a).
142 Zoltán Rihmer et al.
The first Hungarian data set in which the spring peak for suicide was demon-
strated derived from the 1930s (a seasonal pattern was similar for both sexes)
(Lester and Moksony, 2007). Analyses using data from later years (1980–1999 in
one study, 1970–2000 in another study and 1998–2006 in a third study) have
also confirmed a peak in the number of suicides in spring–summer and a trough
in autumn–winter (Lester and Moksony, 2003; Zonda et al., 2005; Sebestyén
et al., 2010). Only one of these studies investigated genders separately, and this
one did not find – the above-mentioned – autumn peak for females (Zonda et al.,
2005). All three studies reported that seasonal fluctuation of suicide was decreas-
ing during the periods examined (Zonda et al., 2005; Lester and Moksony, 2003;
Sebestyén et al., 2010). The one study which investigated seasonal fluctuation of
suicide by age (Zonda et al., 2005) found that the decrease pertains only to
the young cohorts, while Sebestyén et al., (2010) – investigating a different time
period – described how the decrease in suicide seasonality is mainly the con-
sequence of the significant decrease among males. Analysing the relationship
between increasing antidepressant utilization and the national suicide rate of
Hungary between 1998 and 2006, there was a significant correlation between the
steadily increasing antidepressant prescription (113 per cent) and the continuous
decline in total national suicide rate (23 per cent) as well as both in females and
males (21 per cent and 23 per cent, respectively). Increasing antidepressant
utilization was associated with significantly decreased seasonality of suicides only
among males. The results suggest that decreasing seasonality of suicides could be
a good marker of lowering rate of depression-related suicides in the population
particularly among males (Sebestyén et al., 2010).
Another highly confirmed and noteworthy result regarding temporal
variations of suicide is that more individuals commit or attempt suicide in the
first days of the week than at the weekend (‘Blue Monday phenomenon’)
(Ohtsu et al., 2009; Erazo et al., 2004; Zonda et al., 2008; Zakharov et al.,
2013). In contrast to seasonal variation that has strong biological correlates
(Rocchi et al., 2007; Praschak-Rieder et al., 2008), this circaseptan fluctuation in
completed suicides should have mainly psycho-social determinants. Similarly to
results from other countries, the average number of suicides peaked on Monday
for both sexes and was lowest on weekend days (for both sexes) in Hungary
between 1970 and 2002 (Zonda et al., 2008).
We investigated the effect of ‘season of birth’ on the risk of completed suicide
in a comfortably large sample (78,779 suicide completers and 6,697,361 control
individuals) in Hungary. We found that in the whole population investigated,
those who were born in the highest risk period (July) have an approximately
13.8 per cent (95 per cent CI: 9.1 per cent–18.6 per cent) higher risk of dying
by suicide than those who were born in the lowest risk period (December).
Hungarian results on the elevated risk of completed suicide among those
who were born in the spring-summer period of the year (compared with
those who were born in the autumn-winter period of the year) agree with the
majority of relevant previous data (Dome et al., 2010a).
 Distribution of suicidal behaviour 143

The role of psychiatric disorders in suicidal

behaviour in Hungary
Although the traditionally high suicide rate of Hungary is the second highest in
the European Community and fifth–sixth highest in Europe, the characteristics
of suicidal behaviour (gender, age, and urban-rural distribution, method of sui-
cide, marital status, seasonality, rate of psychiatric morbidity) are very similar to
those reported from other countries (Rihmer et al., 2013a). In Hungary – similar
to the great majority of developed countries – males consistently show much
higher suicide rates than females (Hawton and van Heeringen, 2009; WHO).
However, the female suicide rate decreased more markedly between 1983 and
2010 (females: 61 per cent decline, males: 39 per cent decline) and while the male
to female suicide ratio was 2.53 in 1983, the same figure was 3.93 in 2010
(Rihmer et al., 2013a).
In a psychological autopsy study conducted more than 25 years ago in Budapest
we found that 63 per cent of 200 consecutive suicide victims had current
depressive disorders (almost half of them had bipolar depression), 9 per cent
schizophrenia and 8 per cent alcoholism (Arato et al., 1988; Rihmer et al.,
1990b). More than half of the depressed suicide victims had medical contact
during their last depressive episode, but less than 20 per cent of them had received
antidepressants and/or mood stabilizers (Rihmer et al., 1990b). In a most
recent case-control psychological autopsy study of 194 suicide victims and
194 controls in Budapest (Almasi et al., 2009), we also found that 60 per cent of
victims (and 11 per cent of controls) had current affective disorder, 26 per cent
of victims (and 38 per cent of controls) had medical contact and 18 per cent of
suicides (and 8 per cent of controls) had taken antidepressants in the last four
weeks before the suicide or before the interview. This study also identified a
number of societal factors that may be important determinants of the suicide risk
in individuals. It has been found that a lifetime history of psychiatric illness, sepa-
rated/divorced/widowed marital status, lower educational level, unemployment
or long-term sick/disabled status, adverse life events within the previous three
months, alcoholism, and current cigarette smoking was significantly more com-
mon among suicide victims, while being responsible for a child less than 18 years
of age and practising a religion were significantly less frequent among the victims
than among the controls (Almasi et al., 2009).
Two independent studies on nonviolent suicide attempters (drug overdose
or poisoning) in Budapest showed that 69–87 per cent of the attempters had
a current major depressive episode (in many cases with comorbid anxiety and/
or substance-use disorders), and the factors of unemployment, living alone and
economically inactive status were overrepresented among them (Balázs et al.,
2003; Rihmer et al., 2009). The strong relationship between suicide attempts and
agitated/mixed depression has been also found both in population-based epide-
miological (Szádóczky et al., 2000) and clinical samples (Balázs et al., 2006).
In spite of the fact that unemployment and alcohol consumption are well-
accepted suicide risk factors (Stuckler et al., 2011; Sher, 2006; Almasi et al., 2009;
144 Zoltán Rihmer et al.
Razvodovsky, 2011) this two indices do not show a statistical correlation with
suicide rate in Hungary between 1992 and 2010. However, a significant positive
correlation has been found between tobacco consumption and national suicide
rate between 1985 and 2008 (Dome et al., 2011), which may reflect that – as
demonstrated also by our studies in Hungary – patients with mood disorders
smoke much more frequently than nonpsychiatric persons (Dome et al., 2005)
and smoking is a suicide risk factor (Rihmer et al., 2007; Almasi et al., 2009).
Moreover, smokers are significantly more impulsive and drink more alcohol than
nonsmokers (Mitchell, 2004; Ostacher et al., 2009), and it is well demonstrated
that impulsive-aggressive personality features and alcohol-related problems are
powerful predictors of suicidal behaviour (Mann et al., 1999; Swann et al., 2005;
Razvodovsky, 2011).
Looking at the problem of suicide from the side of a given individual, there is
no doubt that suicidal behaviour is the result of the complex interplay between
macro-social and personal suicide risk factors, the most powerful of them is the
current episode of major depression (Isacsson, 2000; Rihmer et al., 2002; Rihmer,
2007; Hawton and van Heeringen, 2009). In agreement with international
findings, several studies demonstrated the important role of depression in suicidal
behaviour in Hungary, as we will discuss below. This is particularly important
from a practical point of view, as depression is one of most easily amendable
suicide risk factor. Accordingly, investigating the regional distribution of recog-
nized and treated depressions and suicide rates in 20 regions of Hungary in 1985,
1986 and 1987, the suicide rate showed a significant negative correlation with
the rate of treated depressions in each of the three years: the higher the rate
of treated depressions, the lower the suicide rate in the given region. It is
also important to note that no such relationship was found regarding treated
schizophrenic cases (Rihmer et al., 1990a).
While the suicide rate of Hungary showed a steady (46 per cent) decline
between 1983 and 2006, most of the post-communist countries exhibited
decrease in their suicide mortality only from the mid-1990s, several years after the
big political/economic changes started around 1990. On the other hand,
however, the greatest decline in national suicide rate in the world (more than
65 per cent) between the mid-1980s and 2010 was detected in Denmark, that is
not a typical post-communist country. This shows that political/economic change
was not the main contributor to this favourable trend. However, between 1983
and 2006 the prescription of antidepressants increased by ten-fold. The negative
correlation between antidepressant prescription and national suicide rate in
Hungary between 1985 and 2011 is well demonstrated in several previously pub-
lished papers showing that better recognition and more widespread treatment of
depressive disorders, as reflected in the increasing antidepressant utilization, seem
to be one of the main contributing factors in the markedly declined suicide rate
of Hungary in the last three decades (Rihmer et al., 2001; Rihmer, 2004; Berecz
et al., 2005; Kalmar et al., 2008; Sebestyén et al., 2010; Dome et al., 2011).
Similarly, a statistically significant correlation between increasing anti-
depressant utilization and decreasing national suicide rates have been reported
 Distribution of suicidal behaviour 145
recently from several countries (Ludwig and Marcotte, 2005; Ludwig et al.,
2009), including Sweden, Denmark, Finland, Norway (Bramness et al., 2007;
Isacsson, 2000; Søndergård et al., 2006), the United States (Grunebaum et al.,
2004), Japan (Nakagawa et al., 2007) and, as mentioned above, from Hungary
(Rihmer et al., 2001; Rihmer, 2004; Berecz et al., 2005; Kalmar et al., 2008;
Sebestyén et al., 2010, Dome et al., 2011). Although ecological association does
not mean causality, consider that:

1. There is a strong relationship between untreated major depression and

suicide (Baldessarini et al., 2006; Moller, 2006; Rihmer, 2007).
2. The appropriate acute and long-term treatment of patients with major
depressive and bipolar disorders markedly reduces the suicide mortality even
in this high-risk patient-population (Baldessarini et al., 2006; Moller, 2006;
Rihmer, 2007) and initially suicidal depressives become nonsuicidal with
antidepressant treatment (Rihmer, 2007; Tondo et al., 2008).
3. The annual prevalence of major depressive episode in the population is
around 6–8 per cent (Rihmer and Angst, 2005; Szadoczky et al., 1998).
4. Studies with more sophisticated methods than the simplest ecological one
also supported the theory that antidepressant treatment is protective against
suicide on the population level (Isacsson and Ahlner, 2013; Isacsson et al.,
2009).

It is logical to assume that more widespread treatment of depression is one

of the main causes of declining suicide rates in countries where antidepressant
utilization recently increased markedly. On the other hand, however, as national
suicide rates are affected by many known (see above) and unknown factors
(Gunnell et al., 2003; Preti, 2002), estimating the exact impact of better treatment
of depression on declining suicide rates is not easy.
The increase in antidepressant utilization, as reflected in antidepressant
prescriptions, is only a proxy marker of greater access of patients to appropriate
care, and the higher population density of doctors in general (Rihmer et al., 1993;
Tondo et al., 2006) and psychiatrists and psychotherapists in particular (Rihmer,
2004; Tondo et al., 2006; Kapusta et al., 2009) is negatively associated with
national and regional suicide rates. It is likely that many patients receiving
antidepressants also receive lithium and other mood stabilizers as well as receiving
more frequently supportive or specific psychotherapy for depression. Between
1982 and 2000 the number of psychiatrists in Hungary increased from
550 to 850, as well as the number of outpatient psychiatric departments
(from 95 to 139), and the number of SOS telephone services (from 5 to 28)
(Rihmer et al., 2001). It should be also noted that between 1990 and 2010 the
number of telephones (the best mean for rapid communication even in the case
of suicidal crisis) increased by five-fold in Hungary and recently the number of
ordinary and mobile phones has surpassed the number of individuals in the whole
population. Although it is impossible to measure, it seems likely that the new
democratic political system since 1990 (including freedom of religion and several
146 Zoltán Rihmer et al.
newly founded civil organizations) also plays an important role in this favourable
process. Therefore, the decrease of suicide rates could reflect a general improve-
ment in mental health care rather than being caused by increasing antidepressant
sales alone. The robust increase of antidepressant prescription in Hungary remains
the only consistent correlate of a declining suicide rate in Hungary in the last
25–30 years (Rihmer et al., 2001; Rihmer, 2004; Kalmár et al., 2008; Sebestyen
et al., 2010; Dome et al., 2011), indicating that better recognition and treatment
of depression are one – but not the only – important contributor to this favour-
able change. On the other hand, however, recently we have suggested that the
increasing unemployment rate after 2005 might be one of the contributing fac-
tors that accounted for the disappearance of a strong decreasing trend from the
suicide rate in 2006 that stabilized around 24/100,000/year between 2006 and
2011 (Rihmer et al., 2013b). The exact causes, the role of possible contributory
factors as well as the relationship between them remain to be elucidated. Yet it
seems increasingly obvious that patterns and trends in suicide rates in Hungary
are determined by a delicate interplay between various genetic, psychiatric, cul-
tural, economic, political, social and treatment-related factors specific to Hungary,
determining not only baseline suicide rates but also the rises and falls.

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11 Suicide in the United
States military
Tracy A. Clemans and Craig J. Bryan

Overview of suicide in United States military

Beginning in 2004, the suicide rate among active duty military personnel in the
United States (US) Armed Forces doubled and became the second leading cause
of death in the US military (Ramchand et al., 2011). Prior to this time frame,
the suicide rate of active duty military personnel was lower than the rates
within the US general population, however, it is noteworthy that comparing
these two populations can be challenging for a number of reasons. First, the
demographic make-up of the military and general population varies considerably,
with military personnel generally being younger, male, and Caucasian as
compared to the general population (DOD, 2011). This difference in demo-
graphics introduces important risk factors such as gender, age, and race, which
must be considered and adjusted for when making comparisons between these
two populations. Additionally, the procedures utilized regarding how suicide-
related data is reported between states within the US and the Department of
Defense (DOD), and between states in the US and other geographic regions
differ, resulting in statistics on suicidal behaviors that are not derived from stan-
dardized surveillance database or methods. For example, the differences in report-
ing methods is evident as military suicide statistics are generally reported monthly,
whereas general population suicide statistics are often reported several years
following the actual year being reflected (i.e., 2013 rates reported in 2015). All
of these factors make contextualizing trends in US military suicide compared to
the US general population a challenge with direct comparisons between US
military and US civilian suicide rates generally not feasible.
Regardless of these limitations, it is well documented that the suicide rates
between the US military and US general population have closed during the
past decade. The suicide rate for the US general population typically is around
19 per 100,000 individuals; whereas the US military suicide rates is traditionally
10 per 100,000 individuals (Ramchand et al., 2011) after adjusting for differences
in demographics such as age, gender, and race. However, beginning in 2004 the
US military suicide rate began to steadily rise and surpassed the adjusted general
population rate by 2008. The increase in this suicide rate occurred within all
branches of the US military, however, the Army and Marines experienced the
154 Tracy A. Clemans and Craig J. Bryan
most significant upsurge with the rate being 20 per 100,000 within the Army in
2011 (Department of Army, 2011). As the military suicide rate increased, the
US general population suicide rate increased as well (Centers for Disease Control,
2013), although this growth was much smaller in magnitude.

Risk factors for suicide with United States

military personnel
There are multiple risk factors and variables that have contributed to the rise in
the US military suicide rate. Death by suicide is most likely to occur among
Caucasian men using a firearm (DOD, 2011) with the largest proportion of active
duty personnel dying by a self-inflicted gunshot wound (Anestis and Bryan,
2013). Other risk factors for suicidal thoughts and attempts among service
members include a history of trauma, or being the victim of interpersonal violence
(e.g., sexual assault or domestic battery) with multiple victimizations increasing
this risk (Bryan McNaughton-Cassill, Osman, and Hernandez, 2013). Likewise,
active duty personnel who have a history of childhood physical and sexual
abuse and household dysfunction are an increased risk for later suicidal
behavior (Brodsky and Stanley, 2008; Bruffaerts et al., 2010; Dube et al., 2001;
Joiner et al., 2007; Nock and Kessler, 2006) with this association being partially
mediated by the occurrence of mental disorders among survivors of trauma
(Dube et al., 2001). A recent systematic review examining military sexual trauma
(MST) and suicide (Monteith et al., 2013) found two studies in which MST was
significantly associated with an increased risk for suicidal behaviors (Kimerling
et al., 2007) and suicide attempts (Gradus et al., 2013). As a result of exposure
to trauma, service members can develop post-traumatic stress disorder (PTSD),
severe depression, and guilt which are all associated with an increased risk for
suicidal thoughts and behaviors (Bossarte et al., 2012; Bryan, Clemans,
Hernandez, and Rudd, 2013; Bryan, Morrow, Etienne, and Ray-Sannerud, 2013;
Rudd et al., 2011).
Risk factors for suicide attempts and death by suicide among military personnel
also include relationship conflicts and interpersonal problems, legal or disciplinary
issues, financial problems, and physical injury (DOD, 2011; Bryan and Rudd,
2012), along with non-suicidal self-injury being overrepresented among military
personnel with suicidal ideation and suicide attempts (NSSI; Bryan, under
review). It is not uncommon for active duty personnel to experience an
increased number of stressors upon their return from deployment and when
family problems or family conflict result from these reintegration issues, there is
an increased risk for suicidal ideation within service members (Kline et al., 2011).
Approximately 25 percent of personnel who served in Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) report psychological prob-
lems post-deployment which also increases the risk for suicide (Hoge et al., 2004;
Hoge et al., 2006).
Similar to risk factors established within the civilian literature, nearly 25 percent
of military personnel who died by suicide were intoxicated or had abused
 Suicide in the United States military 155
substances at the time of their death (Logan et al., 2012). Sleep disturbances
such as very short sleep duration and insomnia are associated with suicidal
ideation and future suicide attempts (Luxton et al., 2011; Ribeiro et al., 2012) in
military personnel. Cognitive risk factors for military personnel include a
perception of being a burden on others (i.e., perceived burdensomeness) (Bryan,
2011; Bryan Clemans, and Hernandez, 2012; Bryan, Morrow, Anestis, and
Joiner, 2010) or that no one cares about them (Bryan, 2011; Bryan, McNaughton-
Cassill, and Osman, 2013) and hopelessness (Bryan, Ray-Sannerud, Morrow, and
Etienne, 2013a).
In recent years, there has been increased attention on the occurrence of
active duty personnel with traumatic brain injury (TBI) secondary to combat
activities as a significant number of Army personnel who were deployed to
Iraq and Afghanistan have experienced a TBI (Hoge et al., 2008; Schneiderman
et al., 2008). Within the civilian literature, several studies established an
increased risk of suicidal behavior among individuals with TBI (Simpson
and Tate, 2002; Teasdale and Engberg, 2001), therefore TBI is thought to
be an additional factor contributing to the rise in the suicide rate among
active duty military personnel. A recent study by Bryan and Clemans (2013)
found that an increased incidence of lifetime and recent suicidal thoughts
or behaviors was associated with the number of TBIs, especially among
service members with two or more lifetime TBIs. The association between
number of TBIs and suicidality existed after controlling for other clinical
symptoms (Bryan and Clemans, 2013). Additionally, TBI is associated with an
increased risk for PTSD and depression (Hoge et al., 2008; Kreutzer et al., 2001;
Schneiderman et al., 2008) and consequently the neuropsychological sequel
of TBI may serve as a factor increasing the risk for suicide among military
personnel. These findings suggest that service members who have sustained a TBI
are an important population to target with appropriate interventions that can
reduce their suicide risk.

Combat exposure and United States military suicide

Studies examining the relationship between deployments, in particular, combat
exposure, and suicide risk within military personnel have had inconsistent
findings. Some studies have established that combat exposure is directly
associated with an increased risk for suicidal thoughts and behaviors among
military veterans (Fontana, Rosenheck, and Brett, 1992; Rudd, in press;
Maguen et al., 2012; Sareen et al., 2007; Thoresen and Mehlum, 2008), despite
this relationship being very small in magnitude. Other studies with active
duty personnel suggest combat exposure/deployment is not predictive of
suicide attempts or death by suicide (DOD, 2011). These studies have been
unable to establish a direct relationship between combat exposure with
suicidal thoughts and behaviors among active military personnel (Bryan
et al., 2013; Griffith and Vaitkus, 2013; Leardmann et al., 2013). Of note,
the strongest predictor of suicidal ideation and suicide attempt in the year
156 Tracy A. Clemans and Craig J. Bryan
post-deployment among US personnel is suicidal ideation and suicidal
behaviors that occurred prior to the service member’s deployment (Griffith and
Vaitkus, 2013).
The majority of military personnel, specifically less than one in six individuals,
reported thinking about combat on the same day in which they attempted suicide
(Bryan and Rudd, 2012). Recent findings have also suggested that an association
between suicidal thoughts and behaviors and combat exposure were moderated
by the age of individual, with this relationship only occurring among older mili-
tary veterans and personnel (Bryan Hernandez, Allison, and Clemans, 2013).
These studies reflect the complexity of the relationship between combat exposure
and suicide, therefore conceptualizing combat exposure as being a chronic pre-
disposition for suicide risk, similar to other types of trauma, may be helpful.
As such, combat exposure which can increase an individual’s vulnerability to
other risk factors like guilt (Bryan, Morrow, Etienne, and Ray-Sannerud, 2013)
may serve as a distal or long-term risk factor for suicide instead of a proximal or
short-term risk factor for suicide.

United States military culture and suicide

The distinct culture within the US military is one of the most important consid-
erations when looking at how suicide among military personnel differs from the
general population. As providers treat suicidal military personnel and veterans,
culturally relevant issues to consider during the treatment process include mental
toughness, collectivist orientation, self-reliance, self-sacrifice, and fearlessness
of death (Bryan, Jennings, Jobes, and Bradley, 2012). In terms of mental tough-
ness, the military culture values courage, strength, and resilience and perceived
weakness is often avoided by military personnel even when they experience
discomfort, distress, pain, or adversity. The military cultural norm is experiential
avoidance and emotional suppression which are two coping strategies that,
in actuality, are extremely adaptive for personnel who are in situations that are
high-risk or extremely dangerous, like the combat zone (Bonanno, 2004). In the
short term, emotional suppression and avoidance are effective; however long-
term suppression can lead service members to experience emotional distress
(Beck et al., 2006; Shipherd and Beck, 1999) and suicidal thoughts and behaviors
(Najmi et al., 2007).
The military culture highly values group membership therefore placing the
goals and needs of the group over the individual’s needs and goals is reinforced
and a normal part of the culture (McGurk et al., 2006). Fortunately, high levels
of group cohesion can be a buffer against emotional distress and can reduce the
suicide risk of military personnel. This collectivist orientation within the military
emphasizes the protection of the group’s identity, reputation, and security which
can, unfortunately, negatively impact service members who may be seeking help
(e.g., mental health treatment) from individuals who are considered to be ‘out-
side’ of the group (Chang and Subramaniam, 2008). Providers and clinicians
should be mindful of the value placed on military group cohesion and incorporate
 Suicide in the United States military 157
a system-based perspective as they conceptualize and formulate treatment for
suicidal personnel.
The US military culture expects its personnel to competently perform duties
and to navigate any obstacles or problems in order to successfully complete the
mission at hand. This value of self-reliance within the military views service mem-
bers who may be experiencing deficiencies in problem solving due to emotional
distress to be ‘substandard’ and, unfortunately, asking for help from others fur-
ther violates this expectation of self-reliance. If military personnel continue to
experience difficulties with self-management secondary to emotional problems
(e.g., suicidal service members), then the value of self-reliance can actually under-
mine the individual’s sense of strength and elitism. Providers, therefore, will find
it helpful to recognize that suicidal personnel can feel trapped between the desire
to improve and the desire to ‘fix things’ independently. Thus, it may be beneficial
for clinicians to frame the treatment process as a means for service members to
achieve or recapture their self-reliance and autonomy.
Self-sacrifice and selflessness are two highly respected values within the military
culture and are defined when service members sacrifice themselves for the greater
good of others. This value means that military personnel will suffer injuries or
even death in order to protect others. Therefore, providers can assist suicidal
personnel by helping them to understand the distinction between the military
value of ‘giving’ their life for the protection of others (i.e., self-sacrifice) versus
‘taking’ their own life (i.e., suicide).
The military culture also reinforces fearlessness about death, as service mem-
bers are explicitly trained to overcome the fear of death. This process occurs via
extensive conditioning (Charney, 2004) throughout the course of military train-
ing and leads to habituation to the fear of death, which becomes further solidified
during combat. The fear of death is considered a protective factor against suicide
(Linehan et al., 1983; Osman et al., 1996), thus when this fear is extinguished
among military personnel, the risk for suicide of these service members increases.
Clinicians would benefit from integrating this notion of fearlessness of death
when conceptualizing the cases of military personnel with whom they are work-
ing. Of note, military personnel also have the increased ability to make a suicide
attempt. in part, due to access to highly lethal weapons (e.g., guns). Therefore,
providers can reduce suicide risk of personnel by routinely providing means
restriction counseling, especially with service members who have access to or
own firearms.
The culture of mental health within the US is very different from that of the
US military culture. The US mental health culture is clinically oriented and
psychological problems are typically conceptualized as deficiencies or from the
perspective of being part of an individual’s ‘illness’. In contrast, the military cul-
ture emphasizes a strength-based perspective (Bryan and Morrow, 2011) and
reinforces the values that were described earlier in the chapter (i.e., self-reliance,
self-service). The differences in these cultures clash as the typical mental health
care approach reinforces individuals being emotionally vulnerable (e.g., ‘It’s okay
to let your guard down and talk about it’) versus the military approach which
158 Tracy A. Clemans and Craig J. Bryan
emphasizes service members being strong and mentally tough. One of the con-
tributors to the mental health stigma among military personnel is the disparity of
the two cultures (Bryan and Morrow, 2011), as most anti-stigma efforts utilize
an approach in which personnel are encouraged to adopt the cultural norms
within the traditional mental health care system (e.g., ‘It’s okay to get help’) and
abandon the values inherent within the military culture. One way in which anti-
stigma efforts can modify this traditional approach is to adopt a multicultural
perspective in which mental health services conform to the cultural norms of the
military instead of service members being asked to adapt to traditional mental
health care norms.

Fluid Vulnerability Theory (FVT) of suicide

and the suicidal mode
In addition to providers having a global, multicultural perspective on how mental
health stigma and military culture can impact suicidal personnel, it is imperative
providers have a theoretical foundation to assist in conceptualizing the suicide risk
of service members. Fluid Vulnerability Theory (FVT; Rudd, 2006) is a cognitive
theory that can aid in understanding the process of suicide risk over the short
(acute) and long (chronic) term with military personnel. Within FVT is the con-
cept of the suicidal mode which has four domains: (1) cognitive system or the
suicidal belief system; (2) feelings or the affective system; (3) physiological sys-
tem; and (4) the behavioral-motivational system. These four systems work
together when a service member experiences an internal (e.g., thought) or
external (e.g., loss of a relationship) precipitant or stressor. The outcome of the
activation of these systems is the suicidal state or suicidal episode, in which
military personnel can experience cognitions such as ‘I am unlovable’ or ‘I am a
burden to others’, emotions like shame or guilt, physiological arousal (e.g.,
agitation, sleep disturbance), and/or associated death-related behaviors
(non-suicidal self-injury, rehearsal behaviors) (Rudd, 2006).
FVT conceptualizes that a service member’s vulnerability to suicide is variable,
although it is still identifiable and can be quantified (Rudd, 2006). FVT has a
fundamental assumption that suicidal episodes are time-limited (Litman, 1991;
Rudd, 2006). Additionally, FVT hypothesizes that the baseline risk for suicide, or
the threshold at which the suicidal mode is activated, varies among individuals.
For example, some military personnel may have a threshold that is high in that
their suicidal mode is never activated, whereas other service members may have a
lower threshold in which an external stressor (e.g., loss of a relationship) can easily
trigger the suicidal mode.
The baseline suicide risk level of military personnel is determined by static
factors, including developmental and historical factors such as genetic
vulnerabilities, previous suicide attempts, history of abuse, and impulsivity (Rudd,
2006). According to FVT, the baseline risk for service members with a history of
multiple suicide attempts (e.g., two or more attempts) is higher and endures for
a longer period of time (e.g., greater chronic risk) as compared to personnel who
have had one or zero suicide attempts (Rudd, 2006; Rudd et al., 1996; Clark and
 Suicide in the United States military 159
Fawcett, 1992). Clinically, this increased risk for personnel with multiple suicide
attempts is important for providers as they conceptualize the baseline risk
level of personnel with whom they are providing care. Likewise, service members
with a history of multiple suicide attempts have fewer available protective factors,
which ultimately are those variables that reduce the likelihood of suicidal behaviors
and death by suicide, such as family support, positive coping skills, problem
solving skills, and other interpersonal resources (Rudd, 2006). Therefore, a
focus within treatment on increasing a service member’s protective factors
(e.g., improving problem solving) is imperative in reducing their suicide risk.
Another assumption inherent in FVT is that once military personnel experience
the resolution of an acute suicidal episode, they will always return to their baseline
risk level (Rudd, 2006). FVT postulates that a service member’s suicide risk is
elevated by aggravating factors which are internal and/or external precipitant
stressors. For example, aggravating factors may include impaired problem solving,
cognitive rigidity, or poor emotion regulation with all aggravating factors
falling into one of the four suicidal mode domains discussed earlier. When the
suicidal mode is activated by one of these aggravating factors, all four of the
domains (i.e., cognitive, affective, physiological, and behavioral) are involved via
synchrony of action. Despite an increased risk for suicide during this time frame,
this risk only occurs for limited periods of time (e.g., hours, days, weeks) as the
human body is unable to maintain this type of arousal for indefinite periods of
time. When a service member’s physiological arousal level eventually decreases,
even if only slightly, the service member will no longer be an imminent risk of
suicide. This decrease in arousal level typically leads to more balanced thoughts
(e.g., ‘Maybe I can cope with this and do not need to kill myself ’) which,
fortunately, reduces the service member’s risk level.
Another assumption within FVT is the severity of the suicidal episode is
dependent on the interaction between baseline suicide risk and the severity of
aggravating factors (Rudd, 2006). For example, if a service member experiences
a reemergence of anxiety symptoms (affective domain), it is the interpretation or
meaning they make of the change in symptoms that is noteworthy (e.g., ‘I have
no future because I will never get better’). These maladaptive beliefs can activate
the suicidal mode thus increasing the service member’s suicide risk level. The final
assumption within FVT is the acute risk of military personnel will begin to resolve
when aggravating factors/stressors are effectively targeted during the crisis
period. Therefore, the primary target within treatment should be focused on
current symptoms (cognitive, physiological, and affective) and behaviors. In the
following section, we will discuss how providers targeting a service member’s
aggravating factors within treatment can initiate this process.

Interventions to reduce suicide risk with United States

military personnel
Despite the significant problem of suicide among US active duty military person-
nel and veterans, there is a dearth of studies that have evaluated specific inter-
ventions for treating suicidality within this population. Recently, brief-cognitive
160 Tracy A. Clemans and Craig J. Bryan
behavioral therapy for suicidality (BCBT-S) was implemented as part of a ran-
domized control trial with suicidal active duty Army personnel in Fort Carson,
Colorado. As a part of this trial, 152 personnel were randomized to either BCBT-S
or treatment as usual (TAU) and were followed up to 24 months. Preliminary
findings indicate the suicide attempt rate with personnel who received BCBT-S
versus TAU reduced by 50 percent at both 6 and 12 months (Rudd et al., 2013).
Additionally, preliminary results indicate a significant reduction in self-reported
PTSD symptoms with personnel who received BCBT-S versus TAU, at both
6 months and 12 months (Rudd, 2013). Due to the success of BCBT-S, we want
to conclude this chapter by discussing the important components of this treat-
ment which aided in a significant reduction in suicidal behavior of US service
members.
BCBT-S is a modification of a previously tested and empirically supported
approach to treating suicidality (Rudd et al., 1996, 2000). The primary focus of
BCBT-S is the service member’s suicidality regardless of their Axis I and/or Axis
II diagnoses, along with the treatment being focused on the suicidal mode
(i.e. cognitive, affective, physiological, and behavioral factors), including core
beliefs and automatic thoughts that increase a service member’s suicide risk.
BCBT-S consists of 12 one-hour sessions and is organized into three separate and
sequential phases: emotion regulation, cognitive restructuring, and relapse
prevention. As the service member demonstrates a mastery of skills and concepts
from earlier phases, they then progress to each subsequent stage within the
treatment (Bryan et al., 2012). During BCBT-S, selected interventions are
practiced in-session by personnel with instructions from the therapist and are also
assigned for between-session practice.

Phase I: Emotion regulation skills training

The first phase within BCBT-S has a primary goal of stabilizing and reducing the
service member’s emotional distress through the teaching of basic emotion regu-
lation skills. This goal is accomplished through several tasks – describing the
treatment, conducting a narrative review of the index suicidal episode, psycho-
education about the suicidal mode, developing a treatment plan and crisis
response plan (CRP), and teaching emotion regulation skills. During the narra-
tive review of the index suicidal episode, the clinician asks the service member to
‘tell the story’ of their most recent suicidal episode or attempt with the purpose
of obtaining information about the circumstances surrounding the suicidal crisis.
Before the completion of the first session, the service member is asked to develop
a crisis response plan (CRP) which is a written list of steps they can take during
future emotional crises, in order to reduce the likelihood of engaging in suicidal
behaviors. The CRP is a problem-solving tool that outlines crisis management
steps they should take as soon as they are aware of ‘warning signs’ which indicate
they are in distress or crisis. Clinicians follow up with service members during
each subsequent session to inquire whether they utilized their CRP, how it was
used, any barriers to using the plan, and any needed modifications to increase the
 Suicide in the United States military 161
likelihood they will continue using their plan. Additionally, providers can
obtain permission to integrate family members into the service member’s crisis
management strategies and in limiting or removing their access to lethal methods
(e.g., firearms) as a part of the CRP intervention.
During the remainder of the sessions in phase I, clinicians teach the service
member emotion regulation skills (e.g., controlled breathing, mindfulness), pro-
vide psychoeducation (e.g., sleep optimization), and complete in-session exercises
such as the reasons for living list and survival kit. As the service member gains
mastery of emotion regulation skills in this first phase, typically emotional distress
and suicidal ideation will begin to decrease in severity and subsequently treatment
transitions into the second phase, which is focused on cognitively restructuring
the suicidal belief system.

Phase II: Cognitive restructuring of the suicidal belief system

The primary goal of the second phase of BCBT-S is to undermine the com-
ponents of the service member’s suicidal belief system that are contributing
to and sustaining long-term vulnerabilities for suicidal behavior. This is accom-
plished through written exercises and worksheets designed to teach service
members the essential elements of critically evaluating and reappraising their
automatic thoughts, assumptions, and core beliefs about themselves, others, and
the world. The worksheets utilized during this phase include: (1) A-B-C work-
sheets that help service members understand the connection between their
thoughts and feelings; (2) challenging questions worksheets which are used
to assist in challenging automatic thoughts and core beliefs; and (3) patterns
of problematic thinking worksheets that aid the service member in identifying
problematic thinking or cognitive distortions. During this stage, service members
are also asked to schedule events and activities designed to increase their sense of
self-worth, meaning in life, and social connectedness (i.e., activity scheduling or
behavioral activation). Likewise, providers work with personnel to create ‘coping
cards’ which are 3 × 5 index cards that have a suicidal or maladaptive belief
on one side of the card and a balanced, positive response to the maladaptive
belief on the other side of the card.
In the second phase of treatment, it is common for service members to experi-
ence a change in their sense of identity (e.g., ‘Maybe I’m not such a bad person
after all, and I’m being too hard on myself’). These changes in self-perception
indicate their skill mastery and often correspond with improvements in the service
member’s day-to-day functioning, which signals a readiness to transition to the
third and final phase of treatment: relapse prevention.

Phase III: Relapse prevention

The primary goal of the third phase of BCBT-S is to ensure competence and skill
mastery of the emotion regulation and cognitive restructuring skills taught during
the first two stages of treatment. During this stage, the clinician ‘tests’ the service
162 Tracy A. Clemans and Craig J. Bryan
member’s capacity to flexibly solve problems and effectively implement coping
strategies while emotionally aroused. A relapse prevention task is completed with
the service member during a purposely emotionally aroused state because, it is in
such a state, that a service member’s problem solving capacity declines and when
they are most vulnerable to suicidal behavior. During the relapse prevention task,
the provider asks the service member to recount the sequence of events that
occurred during the index suicidal episode from session one. The service member
is asked to rehearse the suicidal episode and to change the outcome of the index
episode by imagining him or herself using a coping strategy or skill to resolve the
crisis instead of engaging in suicidal behavior. This imaginal rehearsal of the index
suicidal episode is repeated several times, with the requirement that the service
member generate a different solution with every repetition of the task. To further
enhance cognitive flexibility, the clinician increases the difficulty of the task with
each rehearsal by introducing potential barriers as the service member imagines
using self-management or problem-solving skills they identified earlier during
treatment. Intentionally escalating the task’s difficulty is an important way to
teach personnel how to ‘think on their feet’ when confronted with unexpected
challenges or barriers in real life.
After the service member has successfully completed the rehearsal task,
the clinician and service member collaboratively generate hypothetical future
scenarios that are most relevant to the service member’s suicidal mode to
further problem solve. The relapse prevention task is then repeated with
personnel imagining themselves effectively resolving future crises. Once the
service member successfully completes this additional relapse prevention
exercise, BCBT-S can be discontinued with the clinician assessing whether
additional treatment is necessary (e.g., trauma-focused treatment, marital
therapy). Regardless of the ultimate disposition, personnel are informed about
the procedures for re-initiating care in the future and how they can receive
‘booster sessions’ as needed.

Future directions for research in United States

military suicide
Despite many challenges described in this chapter regarding the current state of
suicide within the US military, civilian and military researchers have focused sig-
nificant efforts in recent years on evaluating and improving the mental health care
of US service members. Many of these research efforts have led to improved
suicide prevention programs, increased behavioral health training of providers,
and the implementation of a crisis hotline specific for military personnel and vete-
rans. Work continues across several domains within the military including the
evaluation of current suicide risk assessment measures, further exploration of
suicide-specific psychological interventions, implementation of suicide-specific
interventions, utilization of social media to identify at-risk personnel, and the
adaptation of interventions across clinical settings (e.g., primary care versus
mental health clinics). Although suicide prevention efforts within the US military
 Suicide in the United States military 163
are still ongoing, results to date have yielded promising findings that will further
guide and refine future research.

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12 Contribution of alcohol to suicide
mortality in Eastern Europe
Yury E. Razvodovsky

Suicide is one of the leading external causes of death in many countries and its
burden is expected to rise over the next several decades (Bertolote and Fleishman,
2002; Jagodic et al., 2012). There are a number of possible reasons for this
including lessened social integration, increase in psychiatric disorders, alcohol and
drug abuse (Lester, 1997; Mäkinen, 2006). There is marked geographic variabil-
ity in suicide rates globally, with highest rates being found in Eastern Europe (EE)
(Jagodic et al., 2012). The reason for high suicide mortality in EE is not fully
understood. A number of variables, including socioeconomic factors, religious
and biological background, as well as availability of the health care system should
be considered (Bertolote and Fleishman, 2002; Lester, 1997; Pray et al., 2013).
Although a suicidal act is a multi-causal behavior as a result of an interaction of
biological, psychological and socioeconomic factors, alcohol abuse constitutes
one of the most important risk factors (Hufford, 2001). Alcohol consumption
and suicide rates are considerably higher in the EE countries than in the countries
of Western Europe (WE) (Anderson and Baunberg, 2006; Pray et al., 2013).
Accumulated evidence suggests that the mixture of cultural acceptance of heavy
drinking, the high rate of distilled spirits consumption, and binge drinking pat-
tern is a major contributor to the suicide mortality burden in EE (Anderson and
Baunberg, 2006). Both aggregate- and individual level studies reported a positive
association between alcohol and suicide in different parts of the region (Wasserman
et al., 1994; Landberg, 2008). This chapter summarizes the evidence of the rela-
tionship between alcohol and suicide in the Eastern European countries.

Alcohol and suicide

Alcohol abuse has long been considered an important and probably causal factor
of suicidal behavior (Pompilli et al., 2010). It is generally accepted now that both
acute and chronic alcohol use are among the major behaviorally modifiable factors
that are associated with suicidal behavior (Cherpitel et al., 2004). The exact
mechanism for the association, however, is unclear. Hufford (2001) presents a
conceptual framework of distal and proximal risk factors relating alcohol to sui-
cidal behavior. According to this concept distal risk factors create a statistical
 Alcohol in suicide mortality in Eastern Europe 169
potential for suicide. Alcohol dependence, as well as associated comorbid psycho-
pathology and negative life events, act as distal risk factors for suicidal behavior.
Proximal risk factors determine the timing of suicidal behavior by translating the
statistical potential of distal risk factors into action. The acute effects of alcohol
intoxication act as important proximal risk factors for suicidal behavior among
alcoholics and nonalcoholics alike. Acute alcohol intoxication may trigger self-
destructive behavior by provoking depressive thoughts, decreasing self-control
and constricting cognition that impairs the generation of an effective coping stra-
tegy to avoid psychosocial distress (Hufford, 2001; Pompilli et al., 2010). In their
rigorous review of studies of acute alcohol use and suicidal behavior published
over a 10-year period (1991–2001), Cherpitel et al. (2004) found a wide range
of alcohol-positive cases for both completed suicide (10–69 percent) and suicide
attempts (10–73 percent). Several case-control studies at the individual level have
shown a high prevalence of alcohol abuse and dependence among suicide victims
(Kõlves et al., 2006).
The international literature provides increasing evidence of an association
between alcohol consumption and suicide rates at the aggregate level (Pompilli
et al., 2010). In his classic work, Norström (1995) argues that the effect of
alcohol consumption on suicide rate is stronger in a ‘dry’ drinking culture, char-
acterized by a low per capita consumption with the bulk of consumption concen-
trated on a few occasions, than in a ‘wet’ drinking culture with a high average
consumption which is more evenly distributed throughout the week. The reason
for this is that heavy drinkers in the ‘dry’ culture are more likely to experience
weakened family and community bonds because their behavior is viewed as
marginal. In his comparative time-series analysis based on the data for the period
from 1950–1995 covering 14 European Union countries, Ramstedt (2001) has
shown that an increase in population drinking had a greater impact on suicide in
northern Europe (8.6 percent per liter for men and 11.4 percent for women) than
in mid-Europe and southern Europe (0.6 percent per liter for men and
0.5 percent for women).

Suicide in Eastern Europe

Suicides rates in the EE countries are among the highest in the world (Jagodic
et al., 2012; Razvodovsky and Stickley, 2009). Suicide mortality rates in
the region are highly variable (Pray et al., 2013). The reasons for these
differences have not been fully explained. The variability of socioeconomic,
cultural and biological factors might contribute to the regional differences
in suicide rates (Pray et al., 2013). High suicide rates across EE have been
associated with the dramatic societal changes during the post-Soviet transitional
period (Lester, 1998; Mäkinen, 2006). Most of the post-communist countries
exhibited a decrease in their suicide mortality rates from the mid-1990s (Landberg,
2008). Despite a gradual decline in suicide mortality over the past decade,
the former Soviet republics still have the highest suicide rates in the world
(Pray et al., 2013). In his well-designed study Mäkinen (2000) has presented the
170 Yury E. Razvodovsky
following clusters of EE countries according to the values of the main suicide
mortality variables:

1. The ‘high suicide, unequal sex distribution’ group consisted of Belarus,

Estonia, Kazakhstan, Latvia, Lithuania, Russia, Slovenia, and Ukraine.
Characteristic of this group of countries was a higher-than-average suicide
rate, high sex quota, and a low age quota.
2. The ‘high suicide, unequal age distribution’ group consisted of Croatia, East
Germany, and Hungary. This group was distinguished from the first one by
its relatively low sex quota and a high age quota.
3. The ‘low-suicide, unequal sex distribution’ group was made up of Poland,
Romania, and Slovakia. These countries showed a lower-than-average suicide
rate together with a high sex quota and a low age quota.
4. The ‘low suicide, unequal age distribution’ group included Bulgaria, the
Czech Republic, Macedonia, Serbia, and Montenegro. In these countries, a
lower than average suicide rate was accompanied by a low sex quota but also
by a higher than average age quota.
5. The ‘low suicide, equal distribution’ group demonstrated lower than
average values of the suicide rate, its sex quota, and the age quota. It consisted
of Albania, Armenia, Azerbaijan, Georgia, Tajikistan, Turkmenistan, and
Uzbekistan.

Alcohol in Eastern Europe

Although alcohol is a major risk factor in many parts of the world, EE has the
highest alcohol-attributable burden of disease and mortality (Rehm et al., 2006).
Alcohol makes a large contribution to the difference in mortality observed
between the East and West parts of Europe (Anderson and Baunberg, 2006). In
particular, its effects on health seem to have been especially acute in the countries
of the former Soviet Union where it has recently been identified as one of the
most important factors underpinning the alarming rise in mortality that has
occurred in the post-communist period (Stickley et al., 2007). According to the
estimates alcohol consumption is responsible for 13.6 percent of premature mor-
tality cases among men aged 20 to 64 years in Poland; this figure is 16.3 percent
in the Czech Republic, 22.8 percent in Lithuania, and 25.2 percent in Hungary
(Rehm et al., 2006). Its contribution is especially striking in Russia, where alcohol
may be responsible for more than 30 percent of all deaths (Nemtsov and
Razvodovsky, 2008). The overall volume of alcohol consumption in EE region
is the highest in the world. As reported by the WHO (2003), in 2003 the
average total level of recorded consumption in the region was 14.2 liters, which
is 2.3 times higher than global estimates (6.2 liters). There were also considerable
variations in the levels of total per capita alcohol consumption among the EE
countries. The highest average level of total alcohol was reported in Moldova
(25.2 liters), and the lowest was in Bulgaria (15.0 liters). Countries with relatively
high levels of total alcohol consumption included Hungary (17.6 liters), Croatia
 Alcohol in suicide mortality in Eastern Europe 171
(16.8 liters), Ukraine (16.6 liters), Russia (15.2 liters), Belarus 15.0 liters), and
Lithuania (14.8 liters).
Despite ongoing homogenization of alcohol consumption within Europe
in recent decades, EE represents three historically distinct alcohol cultures:
spirits-drinking countries with a detrimental drinking pattern (Russia, Belarus,
Poland, Lithuania, Latvia and Estonia); wine-drinking countries, characterized by
regular consumption of wine with food and the general acceptance of alcohol
as part of the diet (Hungary, Bulgaria, Romania, Slovenia); beer-drinking
countries (the Czech Republic, Slovakia), although recent trends there betray a
notable rise in the consumption of distilled spirits (Anderson and Baunberg,
2006). Due to differences in consumption level and drinking cultures, EE
countries cannot be regarded as a homogeneous region with regard to how
alcohol affects suicide rates.

Alcohol and suicide in Eastern Europe:

individual level studies
The empirical literature provides evidence of an association between alcohol
and suicide at the individual level in many EE nations. The official autopsy
reports of the Estonian Bureau of Forensic Medicine for the period from
1981 to 1992 show that 48.7 percent of males and 22.0 percent of females
were BAC-positive (blood alcohol concentration) at the time of suicide
(Värnik et al., 2006). Research shows that 74.6 percent of suicide victims in
Slovenia were under the influence of alcohol (Bilban and Skibin, 2005). In this
study, men were drunk in 87.1 percent of cases, women only in 12.9 percent
and the given alcohol levels were substantially higher for men (0.65:0.26 g/kg).
The shares of BAC-positive suicides reach its peak in the 35–54 age group (Bilban
and Skibin, 2005). In Croatia, the average blood alcohol concentration at the
moment of suicide was 0.68 g/kg in male, and 0.29 g/kg in female victims
(Coklo et al., 2008). According to the results of the autopsy, 60 percent of men
and 27 percent of women in Romania were BAC-positive at the time of death
(Jung et al., 2009).
In a Polish sample Binczycka-Anholcer (2006) found that 47.5 percent of men
and 36.0 percent of women who committed suicide had a positive BAC at the
time of death. In a similar study alcohol was found in 39.5 percent of individuals
autopsied in the Department of Forensic Medicine at the Medical University of
Warsaw (Fudalej et al., 2009). In this study, the rates of alcohol-positive suicides
were 43 percent in men and 31.3 percent in women, while the average BAC was
0.17 g/dL and did not differ between genders. Additionally, the researchers
found an association between the selected polymorphism of TPH2 and alcohol-
related suicide phenotype under the recessive model of inheritance. It was also
reported, that alcohol dependence was the stronger predictor of suicide under the
influence of alcohol (Fudalej et al., 2009). Similarly, in a psychological autopsy
study in Budapest, alcoholism was identified as an important determinant of
suicide risk (Coklo et al., 2008). A more recent retrospective psychological
172 Yury E. Razvodovsky
autopsy study has reported that 68 percent of males and 29 percent of
females who committed suicide met criteria for alcohol abuse or dependence
(Kölves et al., 2006).
The findings suggest that alcohol is an important determinant of suicide
rates at the individual level in Belarus (Razvodovsky, 2006a, 2006b, 2010,
2012, 2013). A psychological autopsy study revealed that alcohol abuse and
alcohol dependence were diagnosed in 70 percent of male and 71.4 percent of
female suicide victims (Razvodovsky, 2013). A recent study based on the autopsy
reports of the Bureau of Forensic Medicine of Belarus revealed that 61 percent of
males and 30.6 percent of females were BAC-positive at the time of death
(Razvodovsky, 2010). Positive blood alcohol cases were found more frequently
in men aged 30–59 (66 percent) and women aged 19–39 (48 percent). The
average BAC was 2.2 g/L for males and 2.1 g/L for females (Razvodovsky,
2010). So, there is growing evidence that a substantial number of suicides in EE
are related to alcohol.

Alcohol and suicide in Eastern Europe: population

level studies
Most of the evidence linking excessive drinking and suicide in EE is based
on population data. Both longitudinal and cross-sectional aggregate-level
studies usually report a significant and positive association between alcohol
consumption and suicide (Landberg, 2008; Mäkinen, 2000; Razvodovsky, 2007).
On the basis of the multivariate analysis, Marusic (1999) concluded that the
prevalence of alcohol psychoses appears to be among the most important
predictors of regional suicide rates in Slovenia. Further, Pridemore (2006) has
highlighted a close cross-sectional link between alcohol and suicide in Russian
regions during the mid-1990s.
Recent studies addressing the alcohol-suicide relationship at the aggregate
level applied the sophisticated statistical modeling technique developed by Box
and Jenkins (1976) often referred to as ARIMA (autoregressive integrated mov-
ing average) time-series analysis. This technique minimizes the risk of
spurious correlation. An additional advantage of this approach is that ARIMA
time-series analysis provides a base for comparing the relationship between alco-
hol and suicide across countries. In their time-series analysis Bielinska-Kwapisz
and Mielecka-Kubien (2011) reported that alcohol consumption is strongly and
significantly positively related to the suicide rate in Poland: an increase in
consumption by 1 liter of pure alcohol per capita would increase the suicide
rate by 0.83.
Several studies highlighted a significant aggregate level association between
alcohol and suicide in the former republics of Soviet Union. In their pioneering
work Värnik and Wasserman (1992) revealed a positive and statistically significant
association between alcohol consumption per capita and suicide rates in the
former Soviet Slavic and Baltic republics between 1984 and 1992. Alcohol
appeared to have a lower explanatory value for female suicides compared with
 Alcohol in suicide mortality in Eastern Europe 173
male suicides (Värnik et al., 1998a, 1998b). It was reported that in all the
republics, alcohol can explain a large proportion of suicides: 85 percent in Belarus,
77 percent in Ukraine, 75 percent in the Russian Federation, 65 percent in
Estonia, 63 percent in Latvia, 60 percent in Lithuania (Wasserman et al., 1994).
In his time series analysis data for the period 1965–1999 Nemtsov (2003) has
reported that a 1-liter increase in alcohol consumption is expected to increase
suicide rates by 11.4 percent for the total population (13.1 percent for men and
6.6 percent for women). A more recent update suggests that 1-liter increase in
per capita consumption is associated with an increase in overall suicide rates
of 7.2 percent (8 percent for males and 4.3 percent for females) (Landberg,
2008). In another study based on the Russian time series data between 1980
and 2005, Razvodovsky (2011b) found that overall alcohol consumption is sig-
nificantly associated with both male and female suicides: a 1-liter increase in
alcohol consumption would result in an increase in the suicide rate of 7.0 percent
for males and 3.2 percent for females. The estimated effects of alcohol consump-
tion on the age-specific suicide rate for men range from 0.029 (75+ age group)
to 0.084 (30–44 age group) and for women range from 0.008 (60–74 age
group) to 0.036 (15–29 age group). The estimates of AAF (alcohol-attributable
fraction) for females (35 percent) were lower than the estimates for males
(61 percent). The estimated AAF for men range from 33 percent (75+ age group)
to 68 percent (30–44 age group) and for women range from 10 percent (60–74
age group) to 39 percent (15–29 age group) (Razvodovsky, 2011b). These
findings indicate that the relationship between overall alcohol consumption and
suicide rates was stronger for working-age males. The author argues that it is not
surprising, given that the previous studies identified an unhealthy lifestyle among
middle-aged working-class Russian males with the high level of alcohol consump-
tion (Cockerham, 2000). Moreover, this shows a harmful pattern of drinking
featuring big doses of vodka in a short period of time with a small snack. An
analysis of frequency of drinking by male age groups indicates that the frequency
climbs steadily to a peak between ages 30 and 39, before decreasing slightly
in the ages 40–44 and 45–49 years and from age 50 declines significantly
(Cockerham, 2000).
Several researchers have focused on the role of drinking culture as a possible
explanation of the extremely high suicide rates in Russia (Pridemore and Chamlin,
2006; Razvodovsky, 2009a). The distinctive traits of Russian drinking culture are
the heavy episodic (binge) drinking pattern, the preference for distilled spirits,
and sociocultural tolerance for heavy drinking (Nemtsov and Razvodovsky,
2008). A worldwide assessment of drinking patterns showed that Russia and the
former Soviet republics had the most hazardous pattern of drinking (Rehm et al.,
2006). The findings suggest that binge drinking and suicide mortality are
positively related phenomena in Russia. In their time series analysis employing
ARIMA technique Pridemore and Chamlin (2006) found a positive association
between suicide and proxy for heavy drinking in Russia from 1956 to 2002. The
results from another study based on Russian data from 1956 to 2005 showed a
positive association between fatal alcohol poisoning (as a proxy for binge drinking)
174 Yury E. Razvodovsky
and suicide rate (Razvodovsky, 2009b). In their recent time series analysis Stickley
et al. (2011) concluded that binge drinking had a significant association with the
occurrence of suicide in Russia and the magnitude of the relation is the same
across the course of the later-Tsarist, Soviet, and post-Soviet periods.
Additional support for the hypothesis that an unfavorable mixture of higher
overall level of alcohol consumption and binge drinking of spirits is a major risk
factor for suicide mortality in Russia provides the results of time-series analysis
focused on the relation between the sale of different alcoholic beverages and
suicide rates. It was reported that vodka consumption as measured by sale was
significantly associated with both male and female suicide rate: 1 liter change in
per capita vodka sale was associated with an increase in suicide rates by 9.3 percent
for men and by 6 percent for women (Razvodovsky, 2009a). Instead, the con-
sumption of beer and wine were not associated with suicide rate. The estimates
of the age-specific models for men were positive (except for the 75+ age group)
and range from 0.069 (60–74 age group) to 0.123 (30–44 age group). The esti-
mates for women were positive for the 15–29 age group (0.08), the 30–44 age
group (0.096) and the 45–59 age group (0.057) (Razvodovsky, 2009a).
This research evidence replicates previous findings from other settings, which
highlighted that the relationship between alcohol and suicide is stronger for dis-
tilled spirits relative to total alcohol and wine/beer consumption. On the basis of
pooled cross-sectional time series analysis of US data, Gruenewald et al. (1995)
found that only spirits’ sales displayed a significant relationship with suicide rate
whereas wine and beer sales were not associated with suicide. Similarly, in their
time series analysis Norström and Rossov (1999), based on data from Norwegian
and Sweden, reported that in both countries the suicide rate was related to spirits
sales but not to wine sales: a 1-liter increase in spirits sales in Norway was associ-
ated with a 11 percent increase in the male suicide rate; the corresponding figure
for Sweden, was 14 percent. The strong aggregate level association between
vodka sales, and suicide rate in Russia might be an outcome of a preference for
spirits among heavy drinkers (Nemtsov and Razvodovsky, 2008). The effects of
drinking spirits may also be exacerbated by the way they are drunk as a heavy
episodic drinking pattern is widespread. The heavy drinking of spirits in Russia
may result in high suicide rates due to so-called ‘Mellanby effect’ i.e. the more
rapid rise of blood alcohol concentration and thus intake of spirits implies a large
extent of immediate impairment (Stickley et al., 2011). In addition, the expecta-
tions of aggressive behavior associated with spirits intake might trigger auto-
aggressive behavior (Gruenewald et al., 1995). It appears that acute alcohol
intoxication may act as a disinhibitor in people predisposed to suicide for social
and economic reasons.
The results of aggregate-level studies highlighted that alcohol is among
the most consistent predictors of the suicide rates in Belarus. For example,
results from a time-series analysis based on the data from 1970–2005 suggest a
positive correlation between fatal alcohol poisoning/alcohol-related psychosis
morbidity (as a proxy for alcohol consumption) and suicide rates (Razvodovsky,
2007). The results of another study covering the period 1980–2005 show that
 Alcohol in suicide mortality in Eastern Europe 175
population-level alcohol consumption has a positive and statistically significant
association with the suicide rate, with a 1-liter change in per capita consumption
being associated with a 7.4 percent increase in the suicide rate among males and
a 3.1 percent increase among females (Razvodovsky, 2009c); the estimated
effects of alcohol consumption on the age-specific suicide rates for men range
from 0.024 (15–29 age group) to 0.082 (30–44 and 45–59 age groups). The
estimated effects of alcohol consumption on age-specific rates for women
were positive for age groups 15–29 (0.017), 30–44 (0.047), 45–59 (0.039) and
60–74 (0.017) (Razvodovsky, 2009c). In yet another study, Razvodovsky (2001)
demonstrated a stronger association between alcohol and suicide with the
consumption of distilled spirits (vodka) relative to the total level of alcohol
consumption. Finally, the results of time-series analysis indicated a statistically
significant relationship between fatal alcohol poisoning rates and number of BAC-
positive suicides (Razvodovsky, 2011a).
The role of alcohol as major contributor to a high rural/urban gradient in
suicide rate was highlighted in a recent study indicating the presence of a close
association between suicide and fatal alcohol poisoning rates for rural men and
women in Belarus (Razvodovsky, 2012). Furthermore, the findings on the spatial
relationship between suicides and alcohol psychoses incidence rates suggest that
a regional pattern of alcohol-related problems is a major factor responsible for
suicides rate regional variations in Belarus (Razvodovsky, 2013).
In his time-series analysis Landberg (2008) showed a significant association
between alcohol and suicide in seven eastern European countries. Most import-
antly, he revealed that the sizes of the effects were stronger in spirits drinking
countries with a detrimental drinking pattern. The estimates for females were
markedly smaller than those for men in most countries and did not differ between
the two country groups. The pooled alcohol effect for men in the spirits countries
was similar to that found for northern Europe, while the pooled effect for the
non-spirits countries was larger than those for southern and mid-Europe. The
female pooled effects for both countries’ groups were similar to the pooled effect
for mid-Europe. The spirits-drinking countries obtained higher overall and male
AAF estimates than did the non-spirits countries. For example, Russian and Polish
males stand out with an AAF of 70 percent and 45 percent respectively, whereas
the non-spirits countries range between 31 percent and 37 percent. The female
estimates were lower than the estimates for males in all countries except Bulgaria
(Landberg, 2008).
Collectively, these findings provided support for Norstrom’s hypothesis
suggesting that the suicide rate was strongly influenced by alcohol consumption
in the countries where the drinking culture was characterized by heavy drinking
episodes. Furthermore, these findings add to the growing evidence that the binge
drinking pattern (i.e. excessive consumption of alcohol in the form of spirits)
results in a quicker and deeper level of intoxication, increasing the propensity for
autodestructive behavior. This may be especially true, as the level of per capita
vodka sales in Russia and Belarus seems to be a better predictor of suicide rate
than the overall level of alcohol sales (Razvodovsky, 2001, 2009).
176 Yury E. Razvodovsky
It is important to point out that the size of the bivariate association between
alcohol and suicide for men in EE is substantially greater than for women.
This means that alcohol-related suicide is mainly a male phenomenon.
For example, Wasserman et al. (1994) estimated for the former USSR that
the attributable fraction of alcohol for male suicides (more than 70 percent)
exceeded considerably that for females (24 percent). A more recent estimate
suggests that alcohol may be responsible for 61 percent of male suicides
and 35 percent of female suicides in Russia (Razvodovsky, 2011b). Beverage
preference and harmful drinking patterns might be responsible for the
gender difference in the suicide rate as vodka continues to be the drink of
choice for the majority of men in Russia, while women not only drink less
often than men, but those who do drink, consume vodka less frequently
than men. Indeed, according to a population survey, 44 percent of men and
only 6 percent women reported that they drink an equivalent of 25 cl of
vodka or more at one occasion (Bobak et al., 1999). According to a more
recent study 28 percent of men and 4 percent of women consume at least
200g (86+ g of pure alcohol) on one occasion at least once every 2–3 weeks
(Pomerleau et al., 2008).
In contrast to the studies, presented above, it was shown that the suicide rate
in Hungary declined from 46 per 100,000 in 1984 to 32 per 100,000 in 1998
(−32 percent), in spite of the fact that between 1989 and 1996 there was a
25 percent rise in the alcohol-dependence prevalence rates and a six-fold
increase in unemployment (Kovács, 2008). Similarly, Rancaris et al. (2001)
concluded that the alcohol psychoses incidence rate (as a proxy for alcohol
consumption) could not sufficiently explain the rapid increase in suicide rate in
Latvia during the years 1980−1998. The inconsistent results of epidemiological
studies of the relation between alcohol and suicide suggest that multiple
sociocultural factors influence suicide rates.
Thus, most of the research evidence presented here suggests that alcohol
consumption is a significant determinant of suicide mortality at the population
level in EE.

Natural experiments
Natural experiments, such as sudden and large changes in alcohol con-
sumption level, provide an opportunity to test the efficacy of policy attempts to
reduce the rate of alcohol-related problems in the population. These types of
experiments are being used in social epidemiology and allow a rigorous evaluation
of the efficacy of public health interventions. Russia, due to its high overall level
of consumption, hazardous drinking patterns and its high suicide rate,
provides an important contextual setting for this type of analysis. In recent dec-
ades, Soviet and later Russian governments have adopted a series of restrictive
measures in an attempt to curb the alcohol-related burden. Gorbachev’s anti-
alcohol campaign in 1985−1988 is the most well-known natural experiment in
the field of alcohol policy.
 Alcohol in suicide mortality in Eastern Europe 177
A few studies have examined the effect of the Soviet anti-alcohol campaign on
the suicide rate. For example, Värnik et al. (2006) found that the restrictive alco-
hol policy in Estonia led to a 39.4 percent reduction in suicides in which alcohol
was presented in the blood of the victims, BAC-negative suicides showed a
3 percent increase. Mean BAC-positive suicides decreased by 39.2 percent for
males and 41.4 percent for females from the baseline period to the intervention.
In his study Nemtsov (2003) examined trends in per capita alcohol con-
sumption and suicide rate in Russia from 1965 to 1999 and found that the
anti-alcohol campaign was accompanied by a substantial decline in suicide
mortality: in 1984−1986 there was a drop of 39.1 percent (from 37.9 to
23.1 per 100,000 of the population), while alcohol consumption decreased by
26.8 percent (from 14.2 to 10.5 liters). Most importantly, it was shown that the
number of BAC-positive suicides sank by 55 percent (from 22.0 per 100,000
in 1984 to 9.9 per 100,000) between 1984 and 1986 (Nemtsov, 2003). The
potential benefits of the restrictive policy were clearly demonstrated during
Gorbachev’s anti-alcohol campaign in Belarus when a reduction in the per capita
consumption of alcohol from 13.3 to 6.7 liters between 1984 and 1986 was
accompanied by a fall in the suicide rates from 15.4 to 7.0 per 100,000 of resi-
dents (Razvodovsky, 2001). In another study Razvodovsky (2011a) highlighted
that alcohol-related suicides were more affected by the restriction of alcohol
availability during the anti-alcohol campaign: between 1984 and 1996 the
number of BAC-positive suicide cases dropped by 54.2 percent, while the number
of BAC-negative suicides decreased by 7.1 percent.
It seems obvious that the sudden decline in suicide rate appears to be entirely
due to the anti-alcohol campaign of 1985−1988 that significantly reduced alcohol
consumption by limiting its manufacture and availability. However, despite such
circumstances in which all the newly independent states of the former Soviet
Union have been going through similar transformations, any general trend of
suicide mortality cannot be identified in this country. Such Eastern European
republics as Belarus, Estonia, Latvia, Lithuania, Russia, or Ukraine belong to the
‘high-suicide, unequal sex distribution’ group (Mäkinen, 2000). This group
experienced a substantial drop in suicide rates in 1985−1989, especially for
middle-aged males, followed by a large increase in 1989−1993. It should be
noted, that this country has highest level of alcohol consumption compared
to any other country of the former USSR. Azerbaijan, Georgia, Tajikistan,
Turkmenistan, and Uzbekistan, that belong to the ‘low suicide, equal sex
distribution’ group, demonstrate another pattern of suicide. These republics
demonstrated falling rates of suicide rate for the entire period 1985−1993. It was
shown that changes in the level of alcohol consumption were significantly
correlated with those in suicide in the first group of countries only (Mäkinen,
2000). This evidence conflicts with the theory of ‘social correlates of suicide’, and
confirms the intermediating role of culture in relation to suicides.
Some researchers argue that alcohol is unlikely to provide the universal expla-
nation for the mortality fluctuations during the 1980s in Russia (Wasserman
et al., 1994). They believe that the decrease in suicide mortality rate in Russia in
178 Yury E. Razvodovsky
the mid-1980s could have been related to the political and social liberalization
during the period known as ‘perestroika’, which gave rise to social optimism and
new hope. One can argue, however, that social changes should also have resulted
in increased anomie, which according to Durkheim, is associated with a high
suicide rate (Durkheim, 1966). In addition, Nemtsov has highlighted that in
Russia the number of BAC-positive suicides shrank by 55 percent, while the
number of BAC-negative suicides did not change substantially during Gorbachev’s
perestroika (Nemtsov, 2003). He argues that ‘so-called national optimism was
more likely a projection of the emotions of the more intelligent sections of the
population (including scientists) than of the Russian population as a whole’.
Moreover, it has been shown that the oldest age groups of both men and women
did not experience a reduction in their suicide rates during the anti-alcohol cam-
paign, while working-age males faced the greater decreases in suicide mortality in
the mid-1980s and the subsequent increases in the late 1980s and early 1990s
(Pridemore and Spivak, 2003). Decrease in suicide rates in the Slavic and Baltic
republics during the anti-alcohol campaign occurred to a greater degree for ages
25−54, averaging a drop of 45 percent for men and 33 percent for women
between 1984 and 1986−1988 (Värnik et al., 1998b). In contrast to a pattern of
age-specific suicide rates for women, a distinctive pattern of male suicide rates in
the Slavic and Baltic republics converged with those found in other parts of
Europe during 1986−1988 (Värnik et al., 1998b). It appeared that the anti-
alcohol campaign contributed to a unique pattern of male suicide mortality in this
region, especially in the 25−54 age group. Similarly, it was shown that the pattern
of the age-specific distribution of suicides and fatal alcohol poisonings coincided
during the anti-alcohol campaign (Nemtsov, 2003).
There is strong evidence for the key role of alcohol in explaining the Russian
suicide mortality crisis in the early-1990s. In his well-designed study Mäkinen
(2000) has reported that alcohol consumption was a powerful predictor of
suicide rates in ‘high-suicide, unequal sex distribution’ group of Eastern Bloc
countries (including Russia) which experienced a large drop in suicide rates in
1985−1989, especially for middle-age males, followed by a large general increase
in 1989−1993. This evidence supports the hypothesis that the increase in alcohol
consumption was the main determinant of suicide mortality crisis in Russia in the
early-1990s.
Several scholars have argued that psychosocial distress resulting from the ‘shock
therapy’ economic reform and sudden collapse of the Soviet paternalist system
was the main determinant of the suicide mortality crisis in the former Soviet
republics in the 1990s (Andreeva et al., 2008). A recent cross-sectional time-
series analysis focused on suicide rates and socioeconomic factors in Eastern
European countries after the collapse of the Soviet Union suggests that changes
in suicide rates were related to socioeconomic disruptions experienced during the
transition period (Kõlves et al., 2013). Instead, suicide rates in EE were not asso-
ciated with alcohol consumption during the transitional period. Similarly, Lester
(1998) suggested that the increase in suicide rates in this period may be a result
of the disappointment over the changes in the standard of living after the initial
 Alcohol in suicide mortality in Eastern Europe 179
hope that social conditions would improve rapidly. So, psychosocial distress may
have been an important underlying factor of the suicide mortality crisis in the
former Soviet republics in the 1990s. However, close aggregate level association
between alcohol consumption and suicide rates, as well as the recent findings
from Belarus highlighting the fact that the number of BAC-suicides dramatically
jumped in the 1990s (Razvodovsky, 2011a), strongly supports an alcohol-related
hypothesis and suggests that rather than playing a major causal role, psychosocial
distress may represent a confounding factor.
The key point in debates on alcohol and suicide in Russia relates to the
causes of increase of alcohol consumption in the early 1990s. There is evidence
that alcohol is often used as medication for stress-related discomfort (Koposov
et al., 2002). A prior study revealed that heavy drinking was most common
among men who experienced loss in social standing during the transition
(Yukkala et al., 2008). This suggests that heavy drinking and psychosocial distress
are closely linked since distress increases involvement in binge drinking that
heightens the risk of suicide.
It seems plausible that the psychosocial distress resulting from the reforms
were the main causes of increased demand for alcohol at this time. This demand
was met by factors that increased supply. Following the repeal of the state alcohol
monopoly in January 1992, the alcohol market fragmented, including many pri-
vate producers and importers operating without a license or registration (Nemtsov
and Razvodovsky, 2008). The country was practically flooded by a wave of home-
made, counterfeit, and imported alcohol, mainly spirits (Stickley et al., 2007).
The negative outcomes of an increase of alcohol consumption during this period
included a sharp rise in suicide mortality.
One of the most interesting features of suicide mortality crisis in Russia in
the early-1990s is the gender difference in spite of the fact that men and
women share the same socioeconomic circumstances (Andreeva et al., 2008). It
seems that males were most vulnerable to the stressful experience resulting
from abrupt socioeconomic changes, political instability, unemployment
and impoverishment. This disproportionately affects the working-age male popu-
lation because their work and family roles rendered them more vulnerable to
socioeconomic disruption (Cornia and Poniccia, 2000). Several studies have sug-
gested that men in Russia, as a result of traditional masculine norms, are more
prone to respond to stressful situations with maladaptive behavior such as
increased alcohol consumption, while women have a more adaptive stress
response. Based on interviews conducted with a stratified random sample of
1190 Muscovites Yukkala et al. (2008) concluded that experiencing several kinds
of economic problems is positively related to the risk of binge drinking among
men. In contrast, women seemed less likely to binge drink when experiencing
manifold economic problems. Cockerham et al. (2006) found that in Russia psy-
chological distress promotes frequent drinking among men, but not among
women, even though women reported significantly more distress.
In contemporary Russia, recognizing the central role of alcohol in the mortality
crisis, President Putin signed a law regulating production and sale of alcohol
180 Yury E. Razvodovsky
production in 2005 (Nemtsov and Razvodovsky, 2008). The law contained
regulations aimed at controlling the volume and quality of alcohol products
and requiring the registration of alcohol production and distribution facilities.
In a recent study Predimore et al. (2013) took advantage of this natural
experiment to assess the impact on suicide mortality of a suite of Russian alcohol
policies. They used autoregressive integrated moving average (ARIMA)
interrupted time series techniques to model the effect of the alcohol policy on
monthly male and female suicide counts between January 2000 and December
2010. They revealed that the alcohol policy in Russia led to a 9 percent reduction
in male suicide mortality, meaning the policy was responsible for saving
4000 male lives annually that would otherwise have been lost to suicide.
Another piece of evidence suggesting the close link between alcohol and sui-
cide at the population level comes from Slovenia. Recognizing the high level of
alcohol-related problems, the Slovenian National Assembly passed new legislation
in January 2003 that aimed to reduce alcohol-related harm by restricting alco-
hol’s availability. The law established a minimum age of 18 years for drinking
and purchasing alcoholic beverages and limited where and when alcohol can be
purchased. There is evidence that this new alcohol policy has had an impact
on suicide mortality. In particular, Pridemore and Snowden (2009) assessed the
effect of a national alcohol policy on suicide mortality using interrupted time-
series techniques, and found that the implementation of alcohol policy was fol-
lowed by an immediate and permanent reduction in male suicide mortality. More
specifically, there was an immediate and permanent reduction of 3.6 male suicides
per month, or approximately 10 percent of the pre-intervention average. In con-
trast, the new policy had no statistically significant effect on female suicides.
In a more recent study Zupanc et al. (2013) reported that during the period
before the implementation of the measures which limited the availability of alco-
hol in Slovenia, the BACs of BAC-positive suicide victims were higher than those
tested in the period after the implementation of the act. This evidence suggests
that legislation measures restricting alcohol availability may be an effective means
of BAC reduction in BAC-positive suicide victims. Together with similar findings
elsewhere, these results suggest an important role for public health interventions,
including restrictive alcohol policy, in reducing alcohol-related suicide deaths.
Nevertheless, the impact of natural experiments on suicide mortality is
not always unequivocal. In particular, increasing awareness concerning the rising
level of alcohol-related problems was the main reason behind the implementation
of a new alcohol policy in Lithuania during 2007–2009 (Sauliune et al., 2012).
The major policy innovations included strict regulation of advertising, raising the
excise tax on alcohol, controlling drunk driving, and curtailing illegal alcohol
imports and sales. Implementation of these alcohol control measures resulted in
a significant reduction in the alcohol-attributable burden of violent mortality.
However, despite the successful implementation of the anti-alcohol policy, suicide
rates and YPLL (years of potential life lost) due to alcohol-related suicides had a
tendency to increase among males, while among women it remained rather stable
throughout 2006–2009 (Sauliune et al., 2012). The authors hypothesized that
 Alcohol in suicide mortality in Eastern Europe 181
the increase in suicide rates in this period might be affected by the economic
recession and large rises in unemployment followed by increased psychological
distress.
Collectively, most of the empirical evidence indicates that a restrictive alcohol
policy appears to be one of the most effective suicide prevention policies in EE.
Together with similar findings elsewhere, this evidence suggests an important role
for public health interventions in reducing alcohol-related suicide deaths.

Policy implications
In a number of studies using various designs, alcohol consumption has been
found to be important risk factor for suicide in EE. The high level of alcohol
consumption in combination with detrimental drinking patterns in the EE
countries results in a high level of alcohol-related suicides and a strong association
between alcohol consumption and suicide rates in EE. The proportion of suicide
victims who were under the influence of alcohol at the time of death in EE is
higher than in WE. This evidence is in accordance with aggregate-level studies
that show that the association between alcohol consumption and suicide rates is
stronger in EE countries compared to WE countries. Studies of natural
experiments have also demonstrated a significant impact of alcohol consumption
on suicide rate in EE. In particular, a fairly close aggregate-level match between
alcohol consumption and suicide mortality during Gorbachev’s anti-alcohol
campaigns may be used as evidence suggesting that alcohol is responsible
for a substantial number of suicide deaths. This empirical evidence indicates that
a restrictive alcohol policy can be considered an effective measure of suicide pre-
vention in countries where rates of both alcohol consumption and suicide are
high. The studies presented here suggest that the suicide rate in several EE nations
in addition to overall level of consumption is related to the beverage preference
and drinking pattern. Assuming that drinking spirits is usually associated with
intoxication episodes, these findings provide additional evidence that the drinking
pattern is an important determinant in the alcohol-suicide relationship in EE
countries. These findings support the hypothesis that the association between
alcohol consumption and suicide rates in EE countries is stronger than in WE
countries due to a more detrimental drinking pattern and preference of strong
spirits. This compelling evidence has important policy implications suggesting
that any attempts to reduce overall consumption should also be linked efforts
through differential taxation to shift beverage preference away from spirits.

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13 Media content representation
of suicide in various societies
A critical review
Qijin Cheng and Paul S. F. Yip

Suicide is a serious problem worldwide but shows significant differences

between national/regional suicide rates. Reasons for these great differences be-
tween national/regional suicide rates have been investigated from various aspects.
Socio-cultural contexts, economic conditions, climate, religions, psychiatric
morbidity, accuracy of the registration of suicide, availability of lethal methods,
and the availability of the social/health care system have been taken into account
(O’Connor et al., 2011; Wasserman and Wasserman, 2009).
Media are a crucial part of the socio-cultural context regarding the suicide
problem in society. Ecological studies have provided evidence to demonstrate that
mass media, especially prominent news reports of suicide, can facilitate the
increase in suicide rates at the population level (Fu and Yip, 2007; Gould et al.,
2003; Niederkrotenthaler et al., 2012; Stack, 2003). Also mass media’s
prominent reporting of a new suicide method can facilitate a rapid increase
of the prevalence of the method (Chen et al., 2013; Lee et al., 2005; Yip
et al., 2013). In addition, in survey studies and qualitative interviews, some
suicidal individuals reported that they were influenced by media content, including
non-fictional and fictional media, in terms of suicidal ideation or choice of a
suicide method (Biddle et al., 2012; A. T. A. Cheng et al., 2007; Tsai, 2010),
which endorsed the media content’s impacts.
The media’s effects on suicide are believed to be related with how the
media represents suicide. The term ‘media representation’ is different from
‘media report’ as the former is rooted in the theory of social construction
of reality and the theory of mass-mediated depiction of reality. Modern sociology
and cultural studies commonly emphasize that individuals can only process
symbolic reality which is a representation of the objective reality embedded in
the institutional fabric of society (Adoni and Mane, 1984; Gamson et al., 1992).
The process of reality representation is referred to as the social construction of
reality, where the mass media play an important role. Starting from Walter
Lippmann, a famous writer and journalist in the US, an argument has been raised
and supported that the mass media were not simply reporting the reality but
representing the reality based on their own publishing policies, agenda, and
interpretations (Schudson, 1997).
 Media representation of suicide 187
As far as we know, no study has been conducted to systematically review how
the media represent suicide in different societies and what factors possibly
influence the differences. Furthermore, many previous studies only examined fre-
quency or density of suicide news reports as a quantitative representation of
suicide issues but fewer studies specifically examined the content of suicide
reports. Therefore, the present study aims to fill these gaps through a systematic
literature review. Previous studies found non-fictional media reports, rather than
fictional content, have stronger and more consistent effects on real suicide, and
the effects are often observable in the short term (Gould, 2001; Pirkis and Blood,
2001a, 2001b; Stack, 2005). Hence, the present study limited its review scope to
contemporary non-fictional media content.

Methods
The conduct of this systematic literature screening followed the principles
of the PRISMA statement (Liberati et al., 2009). A demonstration of the
review procedure is shown in Figure 13.1. A literature search was conducted
in October 2013 using ISI Web of Knowledge, Academic Search Premier
(via EBSCO), Communication and Mass Media Complete (via EBSCO), and
Scopus. The search terms combine ‘suicide’ and a set of keywords relating to
the media (media OR newspaper OR press OR print OR television OR radio
OR film OR movie OR music OR book OR fiction OR internet OR web
OR online), which were searched in article titles. In total, 1028 records
were identified through database searching (ISI = 322, EBSCO = 384, Scopus
= 322). After removing duplicates, 786 records remained for first stage
screening.
Records that did not meet the following criteria were excluded from the review:
(1) it must be published in English or Chinese so that they are readable by
the authors; (2) it must use ‘suicide’ to refer to human suicidal thoughts or
behaviors; (3) it must be an academic publication but not news articles, book
reviews, film reviews, nor ads; (4) it must be an original research paper but not
letters, commentaries, or conference abstracts; (5) its study objectives must
include analyzing suicide-related media content; (6) it is not about suicide
bombing or terrorism; (7) the media content in the study is neither historical nor
fictional; and (8) it has full-text available for retrieval. Eventually, 61 papers
remained for review.
Although previous review papers about suicide and the media often con-
structed their review by different media types (Blood and Pirkis, 2001;
Gould, 2001), the present review is more concerned with similarities
and differences in various societies. Therefore, we primarily grouped these papers
by which countries’/regions’ media were studied. Furthermore, we critically
reviewed these papers to identify what factors possibly influenced media content
of suicide in a society, broadly citing from relevant suicide research and media
studies.
188 Qijin Cheng and Paul S. F. Yip

1028 records identified through database searches

242 duplicates were removed

725 records excluded
because: not relevant,
786 records screened not original research paper,
or no full-text in English
or Chinese available
61 full-text papers accessed for eligibility

Figure 13.1 Procedure of the systematic literature screening (proposed by authors).

Results
Only 61 papers published from 1988 to 2013 were identified as relevant
to the research topic, which suggests that the study of media content representation
is still young and developing. These papers were published in journals from
various disciplines, including suicide research, mental health research, public
health research, journalism and media research, sociology, anthropology, and
cultural studies, which demonstrates a broad concern with this research topic.
According to the World Health Organization and other research summaries
(Levi et al., 2003; World Health Organization, 2011), the highest annual suicide
rates are reported from Eastern Europe (e.g. Lithuania, Hungary, Ukraine,
Estonia, etc.) and some Eastern Asian countries (i.e. South Korea, Japan, China),
followed by some Nordic/Western European countries (e.g. Finland, Belgium,
Austria), Southeastern countries/regions (e.g. Hong Kong, Taiwan, Sri Lanka),
and then English-speaking countries (i.e. the United States, the United Kingdom,
Canada, Australia, New Zealand). Latin America and Islamic countries report
lower annual suicide rates, whereas no official suicide data are available at all in
some African countries.
As shown in Table 13.1, there is no clear association between the number of
papers and the suicide rates in the country/region. Rather, a country/region’s
socio-economic development level seems to be more influential on the number
of papers. Media content representation in developed countries/regions, such as
the United States, Australia, and Hong Kong SAR, has been studied more;
whereas there are very few studies conducted in developing countries, such as the
Eastern European countries and China, despite high suicide rates there. No study
has been conducted in South America and Africa, which might be related to low
suicide rates or unavailability of suicide data in these countries.
Based on our review of the literature, we summarized similarities and
differences between studies conducted in different countries/regions and
discussed what factors possibly lead to these similarities and differences.
 Media representation of suicide 189

Table 13.1 Composition of the reviewed papers by country/region*

Composition of the Number of papers Suicide rates per 100,000 per year in most
articles recent year available**

males females

US 17 17.7 4.5
Australia 8 12.8 3.6
Hong Kong SAR 6 19.0 10/7
Japan 6 36.2 13.2
UK 4 10.9 3.0
Canada 3 17.3 5.4
Switzerland 3 24.8 11.4
Austria 3 23.8 7.1
New Zealand 2 18.1 5.5
Sweden 2 18.7 6.8
Finland 1 29.0 10.0
Belgium 1 28.8 10.3
Germany 1 17.9 6.0
Netherlands 1 13.1 5.5
Italy 1 10.0 2.8
Hungary 1 40.0 10.6
Estonia 1 30.6 7.3
Mexico 1 7.0 1.5
Mainland China 2 13.0 14.8
Taiwan 2 20.8*** 11.5***
India 1 13.0 7.8
Israel 1 7.0 1.5

Notes:
* Comparative study of more than one country’s media representation is counted as one study
for each of the countries.
** Data obtained from the World Health Organization (2011). www.who.int/mental_health/
prevention/suicide_rates/en/
** Data obtained from Taiwan Ministry of Health and Welfare (2012), Cause of death statistics.
www.mohw.gov.tw/EN/Ministry/Statistic.aspx?f_list_no=474&fod_list_no=4092

Similarities of media representation across countries

Some common features representing suicide in traditional media were noticed,
when we compared findings from relevant papers. Most of these papers assessed
the quality of traditional media reporting suicide by whether the reports were
compliant with guidelines for responsible suicide reporting that were recom-
mended by suicide prevention organizations, or whether suicide stories reported
by the media match their counterparts in official records of suicides, such as
coroners’ reports or psychological autopsy. These studies were conducted in
190 Qijin Cheng and Paul S. F. Yip
Switzerland (Frey et al., 1997; Michel et al., 2000), Austria (Niederkrotenthaler
and Sonneck, 2007; Niederkrotenthaler et al., 2010), the US (Edwards-Stewart
et al., 2011; Jamieson et al., 2003; Tatum et al., 2010), Australia (Pirkis et al.,
2002, 2009), New Zealand (Thom et al., 2012), India (Ramadas and Kuttichira,
2011), Israel (Weimann and Fishman, 1995), Hong Kong (Au et al., 2004;
Cheng and Yip, 2012; Fu and Yip, 2008), Taiwan (Chen et al., 2012), and
Mainland China (Fu et al., 2011).
These papers found that the media in different countries commonly tend to
over-report youth suicides and under-report elderly suicide (Au et al., 2004;
Chen et al., 2012; Fu et al., 2011; Niederkrotenthaler et al., 2009; Pirkis et al.,
2002). In terms of the suicide person’s background, celebrities or well-known
names, famous or infamous, often attracted prominent reporting (Frost, 2011;
Fu and Yip, 2008; Hamilton et al., 2011; Michel et al., 1995; Pirkis et al., 2002;
Stack, 1996; Tatum et al., 2010; Van den Bulck and Claessens, 2013). In terms
of suicide method, rare or novel methods, such as charcoal burning (Au et al.,
2004; Cheng and Yip, 2012), and violent methods, such as shooting and jumping
(Frey et al., 1997; Niederkrotenthaler et al., 2009; Niederkrotenthaler et al.,
2010; Thom et al., 2012; Weimann and Fishman, 1995), were associated with a
higher likelihood of reporting than suicides by a common method – hanging
(Chen et al., 2012; Pirkis et al., 2002).
Specifically, four studies, published in forensic journals, examined news-
paper reports of homicide-suicide as an approach to monitor this issue in the
United States (Malphurs and Cohen, 2002; Warren-Gordon et al., 2010), the
Netherlands (Liem and Koenraadt, 2007), and Italy (Roma et al., 2012). These
studies assumed that homicide-suicide incidences would highly likely be captured
by the mass media. Therefore, when there is no national surveillance system for
homicide-suicide, they suggested that media surveillance can be an alternative
approach to monitor the incidence. These studies all found that the perpetrators
were predominantly males and the victims were most often women and children.
Firearms/guns were involved in most of the incidents.
In terms of attributes of what led to the suicides, they commonly found that
suicide causes were over-simplified and pre-diagnosed mental disorder or
depression was under-reported (Au et al., 2004; Jamieson et al., 2003;
Niederkrotenthaler et al., 2009; Pirkis et al., 2002; Ramadas and Kuttichira,
2011; Tatum, et al., 2010; Weimann and Fishman, 1995). There is an interesting
case study of the representation of website-related suicides among various
media, including traditional news outlets and news websites, in New Zealand
(Thom et al., 2011). The study found that these news reports often over-
emphasized the role of online technology as ‘enablers’ or ‘preventers’ of suicide
but largely overlooked the contribution of mental well-being to suicide.
The media’s selective reporting patterns are not surprising, given that
rare events are more newsworthy. However, when the readers are not aware
of the media’s selective reporting, the phenomenon may create a myth in their
readers that youth suicides are more severe problems or novel suicide methods are
more popular.
 Media representation of suicide 191
Certainly, we also noticed different findings between these studies and will
report the differences in later sections. Nevertheless, the similarities of media
representation cross-nationally suggest that there are common patterns in terms
of the media’s selective reporting of suicide. These findings supported the
statement that the mass media were not simply reporting the reality but
representing the reality based on their own selection and interpretation.
In addition, common patterns of online representation of suicide were
also observed. When comparing first-three-page search results in Mainland
China (Cheng et al., 2011) and Hong Kong (Cheng, 2011) with those in the
US (Recupero et al., 2008) and the UK (Biddle et al., 2008), the proportion of
anti-suicide search results was all around 32.3 percent to 40 percent, higher
than pro-suicide content. Chronologically, Westerlund (2012) compared first
100 Google search results when using ‘suicide’ as a keyword in 2005, 2009, and
2012 in English. It found that the majority of search results in all of the three
years were suicide-preventive and provided by institutions such as government
departments, NGOs, or associations, whereas there was no pro-suicide result
found in 2012. The findings suggest that online representation of suicide is
mainly formulated by anti-suicide content, in terms of quantity. However, when
assessing the quality of online representation of suicide risk factors or warning
signs by whether they are compliant with scientific research findings, two studies
of English content (Mandrusiak et al., 2006; Szumilas and Kutcher, 2009) both
found that over half of the online content was not evidence-based or too vague
to be useful.
The findings of online representation of suicide show that online platforms
allow organizations and individuals to publish more anti-suicide information,
which break the traditional mass media’s monopoly of media representation.
However, the quality of online anti-suicide content, as well as the quality of
traditional media’s suicide reports, still need to be improved.

Cultural tradition and different media representation

Besides similarities, more research findings demonstrate that media represent-
ation of suicide varies from country to country, or even within the same country.
Cultural tradition is often referred to as the primary reason to explain these
differences.
A cross-cultural study compared suicide reports in Hungary, Japan, the
United States, Germany, Austria, and Finland in 1981 and 1991 (Fekete
et al., 2001) and found significant differences. They observed that the
Hungarian media, compared with the other five counterparts, significantly more
often represented suicide as an effective ‘communicative force’ that evoked
positive valuations in the mass media. Meanwhile, the Hungarian media did
not clearly present positive attitudes toward suicide but ambivalence. In the
Japanese media, suicide was more often framed as related to group affiliation,
attachment, and traditional methods and less frequently with psychopathol-
ogy and abnormality. Meanwhile, the American, Finnish, and German media
192 Qijin Cheng and Paul S. F. Yip
represented suicide more unambiguously, emphasizing pain and the painful cir-
cumstances of suicide, highlighting the consequent sufferings of other people,
and the association with mental illness or criminality. The report was rather brief
and did not provide detailed data of their findings. Nonetheless, it demonstrated
the cross-country differences and warranted more studies on this topic.
We know that Hungary and Japan both suffer from high suicide rates (World
Health Organization, 2011). Suicide rates in Hungary are comparable with
Japan, and were even the highest in the world in the years between 1960 and
2000 (Rihmer et al., 2013). However, the reason for the high suicide rates in
Hungary is not fully understood and the media content of suicide in this country
was rarely studied. By contrast, five papers about media content in Japan were
identified through our literature screen. Previous studies have noticed that
Japanese culture contains norms to tolerate suicide as a way to fulfill one’s respon-
sibility or duty as a member of highly formal and tightly-knit human groups and
classes (Fusé, 1980), which was consistent with Fekete et al.’s findings of Japanese
media content. Furthermore, four studies in our review pool (Ikunaga et al.,
2013; Ozawa-De Silva, 2008, 2010; Seko, 2008), through analyzing suicide
content in online groups, forums, or bulletin boards, demonstrated that the
traditional collective culture in Japan is still represented in suicide-related online
content. Ozawa-De Silva (2008, 2010) argued that the emerging phenomenon
of forming suicide groups/pacts through the internet are still reflecting Japanese
traditional conceptions of self, in which the dominant cultural rhetoric ties self-
hood closely to the social self that is the object of perception and experience by
others. In other words, individuals in such a society often perceive a need for
social connectedness and the fear of social rejection and isolation, which was also
represented in their participation in online suicide groups and wish to die together.
Seko (2008) argued that online discussion forums about suicide not only facili-
tated individuals to look for suicide companions but also served as a social outlet
to freely disclose their pent-up struggles. However, no matter on which side of
the forum, Seko noticed that forum participants’ discourses reflect the collective
culture, collectively committing suicide or collectively transgressing social taboos
of suicide. Ikunaga and colleagues (Ikunaga et al., 2013) found that the posts on
the online BBS contained themes related to those identified in western psycho-
logical theories of suicide (e.g., psychological pain, mental illness, hopelessness,
and escape). However, when analyzing the content more closely, they found that
these themes still represented individuals’ interpersonal concerns (e.g., seeking
connection online, interpersonal conflict, lack of support, and group suicide
wish), which are deeply embedded in Japanese culture.
Japanese researchers’ findings are interestingly contrasted with another
study of online pro-suicide content in Sweden (Westerlund, 2012). Westerlund
conducted a qualitative content analysis with a typical Swedish pro-suicide
website and found that the pro-suicide content on this website was produced as
a critique of the whole of society and its institutions and strongly emphasized
individualism and anti-social currents, which have their roots in Western cultural
and civilization history.
 Media representation of suicide 193
Cultural tradition is not only influencing the media representation of
attitudes towards suicide, but also is influencing media stereotypes of certain
suicide phenomena. Both in Hong Kong (Cheng and Yip, 2012) and Taiwan
(Chen et al., 2012), male suicides were stereotyped as being associated with
work-related issues, unmanageable debt, or legal problems, whereas female
suicides were often attributed to mental illness or relationship breakups. These
gender-specific stereotypes were considered to be related to traditional
Chinese culture that men should be stronger and are the breadwinners in the
family while women are weaker and more fragile (Chen et al., 2012). A study
from Mexico (Reyes-Foster, 2013) highlighted ethnic stereotypes regarding
suicide in the Yucatecan media. It observed that the local media stereotyped
suicides as associated with young, poor, alcoholic men with Mayan last names and
by hanging. The author argued that the stereotyping is rooted in the local society’s
discrimination against Mayan natives and reinforced the stigma of suicide.

Media ecology and different media representation

Besides Fekete et al.’s cross-national comparison, another paper conducted a
comparison of media content in three societies sharing Chinese cultural traditions,
namely, Hong Kong, Taiwan, and Guangzhou (Fu et al., 2011). Suicide rates in
the three societies are all over 13 per 100,000, which can be considered relatively
high. The study screened suicide news articles published in Hong Kong, Taiwan,
and Guangzhou, which are all Chinese societies but have different
political and legal systems, in 2006. The study adopted WHO media guidelines
for suicide reporting to assess suicide news reports in the three societies. It found
that Hong Kong newspapers reported suicide news significantly more frequently
and sensationally (e.g. more often publicizing photos or graphics but less often
including preventive advice) than Guangzhou ones. In addition, the Hong Kong
media more often reported attempted suicide than completed suicide, which was
the reverse of the Guangzhou and Taiwan media. The study did not discuss much
of what led to the differences among the three societies. Nonetheless, its findings
demonstrated that media representation of suicide might be influenced by
complex factors, besides cultural traditions. The media ecology, as well as the
political and legal systems that the media are monitored by, are distinct in Hong
Kong, Taiwan, and Mainland China.
Even within the same society, studies have noticed that tabloid-type media
often represented suicide stories more frequently and sensationally than
others (Cheng and Yip, 2012; Frey, et al., 1997). When the media ecology in a
society includes more tabloid-type media and vigorous media competition, the
overall media representation of suicide news may tend to be more sensational
(Chen et al., 2011; Cheng, et al., in press; Weimann and Fishman, 1995).
The differences between tabloid-type media and the others can be significant
when they are faced with a dilemma of taste versus news value. One example was
when Pennsylvania State Treasurer R. Budd Dwyer invited the media to a press
conference and committed suicide there, the media had to choose whether or not
194 Qijin Cheng and Paul S. F. Yip
to publish graphic photos of the event (Kochersberger, 1988). While tabloid-
type media would maximize news values and represent suicide dramatically,
some media chose to put taste over news values and report suicide with
respect for the bereaved (Blood et al., 2007; Etzersdorfer et al., 2001;
Kochersberger, 1988).
To counterbalance the media’s selective and sensational reporting of suicide,
as mentioned in the previous section, media guidelines for responsible
reporting suicide have been developed and implemented in various countries
(Bohanna and Wang, 2012; Pirkis et al., 2006). However, the implementation
of these guidelines in different societies has faced different effectiveness
(Bohanna and Wang, 2012). In Austria (Niederkrotenthaler and Sonneck, 2007;
Niederkrotenthaler et al., 2010), Switzerland (Frey et al., 1997; Michel et al.,
2000), and Australia (Pirkis et al., 2009), the media representation of suicide has
improved significantly in terms of less sensational and prominent coverage and
more often portrayal of suicide as related to mental illness. However, in Hong
Kong (Fu and Yip, 2008) and the US (Tatum et al., 2010), the effectiveness of
the media guidelines was found to be slight, which was believed to be related to
the highly competitive media ecology in these societies.
Several qualitative studies have conducted an in-depth investigation of the
process of how a suicide event was represented by the media in a certain media
context. These studies demonstrated that journalists and opinion leaders played
important roles in framing suicide stories or problems (Chesebro and McMahan,
2006; Cover, 2012; Frost, 2011; Siu, 2008). In addition, the representation can
be more preventive if the bereaved ones can honestly tell the public that the
deceased suffered from mental illness and suicide prevention professionals can
actively provide suicide prevention information to the media (Jobes and Berman,
1996; Tousignant et al., 2005).

Interaction between online and offline representation

As reported previously, a few studies examined what kinds of content are
accessible online when a person uses a popular search engine to look for suicide-
related information. Besides the similarity that the majority of online content
shows anti-suicide tendency, the proportion of pro-suicide search results in
Hong Kong (Cheng, 2011) (2.8 percent) and Mainland China (4.2 percent)
(Cheng et al., 2011) were much fewer than the figures reported by the US study
(Recupero et al., 2008) (11.7 percent) and the UK study (Biddle, et al., 2008)
(9 percent). In addition, anti-suicide websites in Chinese provided less information
on seeking help and there were fewer government or professional mental health
websites in Chinese. Furthermore, the Hong Kong study noticed that when
using search terms such as ‘suicide method’, ‘charcoal burning suicide’,
and ‘painless suicide’, the first page search results were often pro-suicide
information, which suggests that the online representation of suicide might be
different when the internet users are looking for the information for different
purposes. These findings suggest that the quality of online anti-suicide information
 Media representation of suicide 195
is related to offline availability and quality of mental health services in a society
(Cheng et al., 2011).
In addition, one paper about online discussion of a murder-suicide case in
Estonia (Sisask et al., 2012) showed that online comments on this suicide case
were initiated by traditional media’s reports of the case and many of them
stemmed from dominant topics provided by newspaper articles. On the other
hand, the authors also noticed that some online comments were not directly
related to newspaper articles’ content but individuals’ own value judgments.

Discussion
The study of non-fictional media representation of suicide is relatively young
but developing rapidly and attracting interest from a broad range of disciplines
around the world. However, the development of the field has shown uneven dis-
tribution in various aspects. In terms of geographic regions, more studies were
conducted in developed regions than developing regions, despite the severe level
of suicide rates in the regions. In terms of medium types, textual media content
was more studied than video and audio content. More studies are needed to fill
these gaps.
Our review shows that non-fictional media representation of suicide case or
suicide problems is based on real incidence and can, to a certain extent, reflect the
real incidence. This is why some forensic studies proposed using newspaper
surveillance as an alternative approach to understand homicide-suicide problem
when a national surveillance system is not available. However, when official
records are available to compare with media reports, researchers commonly
observed that the media representation of suicide is different from official records
or professional psychological autopsy findings of suicide, no matter in traditional
media or online media. The media’s selective representation of suicide is related
to some common news values shared by the media across the world. Celebrity
suicides, youth suicides, and suicides using rare or violent methods are commonly
more appealing to the media. The phenomenon reminds us not to under-estimate
how challenging it is if we want to engage the media in suicide prevention
efforts. Meanwhile, the process of media representation of suicide is not only
manipulated by the media, but also by various stakeholders such as opinion
leaders, bereaved ones, suicide prevention professionals, and some readers. The
involvement of various stakeholders can shape or change the media representation
of suicide. One example is the effectiveness of the implementation of media
guidelines in some countries. The other example is the framing of Kurt Cobain’s
suicide led to more suicide prevention when the bereaved ones shared their
experiences with the public and suicide prevention professionals actively engaged
with the media. The implication of these findings is that we need to work with
diverse stakeholders, not merely media professionals, to change the media
representation of suicide toward being more preventive.
In addition, the process of constructing media representation is dynamic
and evolving within a certain social context, where cultural traditions are still
196 Qijin Cheng and Paul S. F. Yip
powerfully influential. Our review shows that the media often interpret or frame
suicide stories following traditional attitudes toward suicide and social stereotypes
of gender, ethnicity, and so on. The media’s representation, furthermore,
reinforces these social norms and stereotypes. Some of these social norms and
stereotypes are actually myths or stigma about suicide and would hinder suicide
prevention. Our review warrants further investigation on the relationships
between cultural traditions, the media representation of suicide, and actual suicide
incidence.
In addition, our review identifies that interactions between online and offline
media lead to more diverse media representation of suicide. For example, in our
review, one study showed that individuals’ online comments on a suicide story
that was reported by traditional media were sometimes not directly influenced by
the media framing but more rooted in cultural traditions. In other words,
traditional media’s function as a gatekeeper of information is weakened by the
accessibility of new media. The online diversity allows suicide prevention
organizations and professionals to contribute more content to represent a more
preventive reality. However, the diversity also allows the traditional stigma
regarding suicide, which might have been restrained in traditional media because
of journalism ethics or implementation of media guidelines, to be represented
through individuals’ representation. Therefore, one can predict that we may
observe more cross-cultural differences rather than similarities of media
representation of suicide on the internet, compared with traditional media.
Whether the prediction is true needs to be tested by future studies. If it is true, it
means that the new media are not only allowing information to flow around the
world but also facilitating local culture or minority culture to regain a voice.
Therefore, our future efforts to promote suicide prevention through the media
will have to be more localized and pay more attention to local culture.
Our review generates a comprehensive and dynamic process of producing
media representation of suicide in various societies. There are still numerous gaps
on this research topic. Besides the uneven distribution of studies in different
societies and different media types, there is also a lack of comparative studies of
media representation, cross-regionally as well as longitudinally.
In summary, our review demonstrates that, for suicide research, examining
media representation of suicide can be a useful research approach to decode social
contexts and norms of suicide at both population and individual levels. For suicide
prevention practices, our review suggests that professionals play a more proactive
role in constructing the media representation of suicide and lead the evolution of
media representation to a more preventive one.

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14 The formal assessment
of suicide risk
Bruce Bongar, Elvin Sheykhani,
Uri Kugel and David Giannini

This chapter examines data and findings on the formal assessment of suicide
risk, and provides recommendations for the consideration of risk factors,
protective factors, and symptoms presentation. In addition, common obstacles
for mental health providers in approaching clients exhibiting suicide risk are
examined and recommendations for a variety of formal and structured approaches
in the assessment of suicide are discussed.

What is formal risk and suicide assessment?

The formal assessment of suicide risk is a practice in which medical professionals,
mental health practitioners, and at times peace officers assess an individual for the
potential to harm the self, others, or for grave disability. If risk is deemed to meet
medical necessity, safety procedures such as safety planning and hospitalization
may be utilized. This chapter will focus on formal risk assessment as it pertains to
suicidal risk. Formal risk assessments include integrating a clinical interview,
behavioral observations such as a mental status exam, historical and contextual
factors, as well as evidence-based practice (Jacobs, 2007). Formal risk assess-
ment varies depending on the setting (such as a hospital, mental health clinic,
or jail), the population at hand, the nature of the disorder, as well as factors
such as severity of psychopathology, and history of past suicidal behavior. Accurate
risk assessment requires a clinician to skillfully integrate clinical judgment
with evidence-based practice to accurately predict behavior. This practice is
inherently difficult, and prone to false positives (Bongar, 1991). Suicide risk
assessment is necessary to establish the likelihood of lethal behavior within the
immediate future. Suicide risk management is an ongoing and collaborative
process in the treatment of suicidal clients. It is conducted systematically and on
the availability of clinically relevant information (Jacobs, 2007).

Why is formal risk assessment important?

Mental health practitioners and health care professionals who lack competence
and training treating individuals with suicidality are shown to hinder recovery, as
well as the disclosure of suicidal thoughts and behaviors. Furthermore, clinicians
 Formal assessment of suicide risk 203
without adequate training often promote stigma, and contribute to poor clinical
outcomes (Meerwijk et al., 2010; Pauley, 2008; Registered Nurses’ Association
of Ontario, 2009). The severity of the suicidal risk informs decisions in terms of
the interventions employed to maintain an individual’s safety, as well as scope of
the treatments going forward. Treatment, including screening and assessment for
suicidality, needs to be considered at all points of entry into the mental health care
system, in day-to-day clinical practice, or at frequent intervals of care, depending
on the treatment setting. The severity of suicide risk assessed should inform
the care interventions, levels of observation, ongoing screening and treatment
approaches (Registered Nurses’ Association of Ontario, 2009). Utilizing formal
risk assessment allows clinicians to begin the stepwise process of assessing the
severity of risk, and target their interventions directly at stabilization and safety
planning for a client.

Suicide rate statistics

Suicide is a major concern for mental health professionals, regardless of the
setting in which they are employed. A mere 5 percent of clinical psychologists
reported that they had never treated a suicidal client. Suicidality is not only
the most common psychological emergency, but also is distinct in its potential
for fatality (Packman et al., 2004). Despite the many deaths due to suicide,
prediction is still quite difficult (Packman et al., 2004). In the United States, each
year there are over 713,000 emergency department visits due to self-inflicted
injuries. Since 1950, completed suicides have risen by 60 percent, and within the
United States over 38,000 people die from suicide each year. (Centers for Disease
Control and Prevention [CDC], 2010a). Research states that one in three practic-
ing clinical psychologists have lost a patient to suicide, and over half of all
practicing psychiatrists have experienced a similar loss (Bersoff, 1999; McAdams
and Foster, 2000; McIntosh, 1993). According to the CDC, suicide remains the
second leading cause of death of individuals 25–34, and is the third leading cause
of death overall for people 15–24. In 2009, 8.3 million Americans reported
having suicidal ideation, and an estimated 2.2 million Americans reported having
made suicidal plans within the last year. An overall estimated 1 million Americans
(0.5 percent of the US adult population) reported making a suicide attempt
(CDC, 2012).

Critical areas and screening of suicidality

The Risk Management Foundation of the Harvard Medical Institution
(RMFHMI) (1996) states that adequate assessment of potentially suicidal clients
begins with a comprehensive psychiatric and psychological evaluation, which
includes a detailed mental status examination, relevant psychosocial history, and
the integration of physical/laboratory examinations. The RMFHMI notes that
suicide risk assessment should occur across four domains: (1) identifying risk fac-
tors, and distinguishing chronic and acute stressors; (2) identifying protective
204 Bruce Bongar et al.
factors; (3) conducting an open, nonjudgmental, and comprehensive inquiry into
the client’s suicidal ideation; and (4) the use of information gathering within the
clinical interview and assessment to distinguish client’s level of risk, treatment
and/or safety planning (Jacobs, 2007; RMFHMI, 1996; Shea, 2002).

Clinical diagnosis and relation to risk

Shea (2002) discussed critical areas of exploration within a risk assessment across
five domains. A client’s current functioning in terms of mental illness is important
in terms of co-morbid disorders as well as co-occurring substance use. Severity
and onset of a mental disorder such as schizophrenia often impact a client’s
propensity toward suicidal behavior (Gliatto and Rai, 1999). Understanding
a disorder’s course and baseline behaviors proves fruitful for clinicians
assessing for potential harm to the self. Disorders such as Borderline Personality
Disorder and Post Traumatic Stress Disorder have been shown to have high
rates of suicidal behavior, and baseline knowledge of tendencies of individuals
diagnosed with these disorders proves helpful to clinicians in understanding
predilections toward such behaviors (Gliatto and Rai, 1999). Substance use
disorders are often comorbid with mental illness; which further impact a
client’s functioning. Substances such as alcohol have a disinhibiting effect,
which often lead to suicidal behavior. In study conducted by the CDC
(2010b), 33.3 percent of all individuals who completed suicide tested positive
for alcohol.

History of suicidal behaviors

During the clinical interview, it is imperative for a clinician to assess a client’s
history of suicidal behaviors. Understanding prior attempts, aborted attempts,
and family history of suicidal behaviors proves crucial in treatment and safety
planning. Being able to view past antecedents to a behavior, and provide possible
coping strategies if similar situations arise are the essence of proper safety planning
(Jacobs, 2007; RMFHMI, 1996; Shea, 2002). Assessing suicide-related
symptomatology provides a basis on which the client and clinician may collaborate
and address risk accordingly. Assessing past and present suicidal ideation,
hopelessness, and low positive emotions are thought to be crucial during the
initial phase of assessment. Degree of hopelessness is one of the best correlates to
attempted and complete suicidal behaviors (Centre for Applied Research in
Mental Health and Addiction [CARMHA], 2007). This further highlights the
need of clinicians at large to understand the contextual and symptomatic factors
that lead to suicidal behaviors. Arming a clinician with baseline knowledge of
suicidal behaviors and symptoms provides utility in the assessment process.
Without this bench-to-bedside approach, a clinician may find themselves
overlooking pertinent and clinically relevant data. Being well read on the current
scientific literature provides a clinician with the ability to provide competent and
comprehensive services.
 Formal assessment of suicide risk 205

Client strengths and vulnerabilities

Understanding a client’s strengths and vulnerabilities provides a clinician further
information within the formal risk assessment process. Suicidal behaviors are
often employed due to inadequate coping abilities. If an individual demonstrates
inadequate coping abilities, these will often become a target of an intervention.
An individual may see their situation as obdurate, or irreconcilable. These
negative cognitions are often compounded by hopelessness, and suicide is
viewed as the only option to escape intolerable distress. These distorted
cognitions are often the root of suicidal behavior, and arming individuals with a
means of coping with their negative situation may bolster hope, and alleviate
some of the distress (Baumeister, 1990; Gliatto and Rai, 1999; Jacobs, 1997;
RMFHMI, 1996). Low distress tolerance has also been identified as vulnerability
for suicidal behaviors. An individual with low distress tolerance may be more
likely to underestimate their ability to cope, and view their psychological distress
as unavoidable by means other than suicidal behaviors (Jacobs, 2007; RHFHMI,
1996; Shea, 2002). Furthermore, understanding a client’s ability for reality
testing provides clinical utility, which is crucial in risk assessment often suicidal
behaviors partly stem from cognitive distortions. Assessing a client’s ability to put
these cognitive distortions to a test of reality provides some alleviation of distress
and may be an individual strength.

Risk factors of self-harm

There is no single predictor that assesses for suicidality with 100 percent
certainty. Assessment of acute and chronic suicidality appreciates the com-
plexity of correlation between risk factors and their compounding effect that
predispose an individual to suicidal behaviors (Bongar, 1991; Sullivan and Bongar,
2009; Shea, 2002). Individuals afflicted by multiple risk factors are often at the
greatest risk for suicidal behaviors. Individuals who express low positive emotions,
have had past suicidal behaviors and express a high degree of hopelessness
are thought to be at the highest risk of self-injurious behavior. Although
individuals who are most likely to complete suicide are the least likely to
explicitly endorse suicidal ideation (Baumeister, 1990; Dean and Range; 1999;
Jacobs, 2007). It is important to note that often stressful life events act as an
antecedent to suicidal ideation and behaviors. Individuals with co-morbid
psychological and medical disorders are thought of as vulnerable populations.
As individuals who are currently in distress experience further distress, a
compounding effect occurs, and often leads to increased hopelessness and may
spur ideation and/or action. Synthesis of clinically relevant information is required
to accurately predict an individual’s potential for self-harm. A multitude of
contextual factors such as an individual’s current support structure (or lack
thereof), socio-economic status, and ability to utilize resources such as impatient
or outpatient psychological services further impact completed and attempted
suicide rates (Hughs, 1996).
206 Bruce Bongar et al.

Protective factors
Although suicidal ideation is prevalent, less than 1 percent of those who
endorse suicidal ideation go on to complete suicide (CDC, 2010). A multitude
of protective factors have been identified that often act as a boon to distressed
individuals that prevent them from attempting or completing suicide. Strong
religious beliefs and fear of social disapproval act as a strong deterrent toward
suicidal behavior (CARHMA, 2007; Jacobs, 2007; Malone et al., 2000). The
notion that one will negatively affect those they care about, acts as both a
deterrent and a means for individuals to seek treatment. Within the scientific
literature, a positive social support group has often been indicted as a protective
factor (Bongar, 1991; CARMHA, 2007; Grob, 1992; Jacobs, 2007; RMFHMI,
1996). A study of individuals diagnosed with major depression who attempted
suicide found that those with positive ‘reasons for living’ were more likely to
abstain from suicidal behaviors. Those with positive coping abilities, positive fam-
ily structure, positive peer supports, and lower levels of hopelessness were less
likely to attempt suicide. These protective factors are theorized to restrain or
guard individuals from attempts. It is important to note that these individuals
would endorse recurrent suicidal ideation, but no suicidal behaviors were reported
or observed (Malone et al., 2000).

Risk assessment based on setting

Suicide assessment protocols vary depending on the population at hand, as well
as the rules, regulations and laws of where an agency or mental health clinic is
located. Examining Veterans Administration (VA) hospitals, general hospitals,
and community mental health centers helps to illuminate the many different
protocols employed when clinical emergencies occur. Emergency rooms in VA
hospitals are frequently the primary contact within the health care system for
suicidal clients (Knox et al., 2012). General hospitals offer a distinct opportunity
in this field of research. Due to the variety of demographics in suicidal clients,
health care professionals in hospitals must be attentive to assessing for suicidal risk
(Mitchell et al., 2005). A majority of individuals with mental illness in the United
States are served in community mental health settings (Chu et al., 2012).

Suicide assessment in VA hospitals

One particular area of concern regarding suicide is that of military veterans.
It is estimated that current and former military members account for 20 percent
of the known suicides in the United States (Bakst et al., 2010). Recent estimates
note that prior and current military service members may account for 22 percent
of those who attempt and complete suicide (Haney et al., 2012). In order to
obtain detailed information about veteran suicidality, researchers have attempted,
via a retrospective study, to determine the content of the health care visits leading
up to completed suicides (Denneson et al., 2010). Denneson and his colleagues
 Formal assessment of suicide risk 207
(2010) reported that 41 percent of the veterans who completed suicide
were assessed for suicidal ideation one year before death. Sixteen percent of these
veterans were assessed for suicide in their final medical or mental health visit.
This information may suggest that screening for suicidal thoughts is not suffi-
cient. Fear of stigma within the military community may make it difficult for
clients to answer such questions honestly (Langford et al., 2013). Traditionally,
formal assessment of suicide risk has been limited to individual factors such as age,
gender, and ethnicity. These assessments have not included numerous factors
which have been shown to be linked with suicidality, such as family structure,
religiosity, and level of personal happiness (Bah et al., 2011).
According to the Department of Veterans’ Affairs (VA) official report
(Haney et al., 2012), a Suicide Risk Assessment Pocket Card has been developed
to assist clinicians to make care decisions regarding individuals who present with
suicidal ideation. The pocket card begins with major warning signs including
threatening suicide, seeking access to pills or weapons, and talking about death
and dying. Other warning signs including hopelessness, rage, increasing sub-
stance abuse, and dramatic changes in mood are of important note (Haney et al.,
2013). Next, there are risk factors and protective factors listed. Risk factors
include current ideation, previous suicide attempts, substance abuse, demograph-
ics, and sexual orientation. Protective factors include social support, spirituality,
children, and a positive therapeutic relationship. This pocket guide recommends
asking a set of screening questions regarding suicide, but only when the clinical
situation or presentation warrants risk of suicidality (Haney et al., 2012).

Suicide assessment in hospitals

In 1998, the Joint Commission issued an alert regarding preventing suicides in
inpatient settings. In 2010, there was an update to this alert which included
patients in general hospitals, surgical units, and emergency departments (Bagian
and Cohen, 2010). Suicide has been particularly difficult to assess for in these
environments. According to a study by Bostwick and Rackley (2007), many
patients who complete suicides have no history of either psychiatric conditions or
previous suicide attempts. It is important to note that in comparison to inpatient
settings, those in general hospital settings have more access to items with which
to complete suicides. In addition, these patients are given more privacy and time
alone; therefore they have more opportunities to attempt suicide (Bagian and
Cohen, 2010). Patients in general hospitals attempt to commit suicide both more
quickly and with smaller amounts of warning as compared to psychiatric patients
(Tseng et al., 2011). Suicides completed in general hospitals also tend to be of
more violent in nature. These include hanging, jumping, and self-inflicted gun-
shot wounds (Suominen et al., 2002). Many of the risk factors mentioned in the
Joint Commission report are similar to those mentioned by the VA. However,
there are risk factors which are specific to the health care environment. These
environmental risk factors include intentional drug overdose and means provided
by the hospital such asphyxiation via plastic bags, elastic tubing, and restraint belts
208 Bruce Bongar et al.
(Bostwick and Rackley, 2007). Tishler and Reiss (2009) noted that poor staff
training, communication issues, low staffing, and a lack of information about
suicide prevention have led to an increased number of attempted and completed
suicides in hospital settings. Suicide is often difficult to assess due to time con-
straints. Many hospitals do not have the resources to implement many risk pre-
vention strategies due to many patients being admitted for a short duration. For
this reason, there is a lack of consistency across hospital settings. General hospitals
must each decide which risk prevention strategies would be the most effective in
their particular facility (Bagian and Cohen, 2010).
The Joint Commission report noted all hospitals were required to identify
patients who were at risk for suicide (Bagian and Cohen, 2010). The three aspects
of this identification were: (1) conducting a risk assessment which includes indi-
vidual characteristics and environmental features which increase or decrease the
chances of a suicide attempt; (2) assessing the individual’s immediate safety; and
(3) providing suicide prevention information to the individual when they leave
the facility (Bagian and Cohen, 2010). The commission suggested two main addi-
tions to these assessment measures. First, the hospital must educate the staff
about risk factors for suicide. Education includes obtaining help in emergencies,
overcoming stigma, and understanding behavioral health. The most important
aspects of this education include particular warning signs and changes in behavior.
When behavioral changes are noticed or warning signs are noted, staff must be
empowered to contact a mental health professional and make appropriate referrals
when warranted. The second addition is implementing risk reduction strategies
provided in the report and decide which would be the most effective in that
particular hospital. These include providing medical professionals with a list of
medications known to be associated with suicidal thoughts, utilizing a suicide
assessment measure, the Suicide Assessment Five-Step Evaluation and Triage
(SAFE-IT); a five-step evaluation which identifies risk factors, and education in
the form of Mental Health First Aid USA; which educates health professionals
regarding myths about suicide (Bagian and Cohen, 2010).
Despite the detail of the Joint Commission Report, these guidelines are
not always followed. Miret et al. (2009) examined the documentation of suicide
risk assessment in clinical records. The researchers found documentation of
907 patients who were seen in emergency rooms after suicide attempts.
Nearly a quarter of these reports have been considered incomplete. Using
more stringent methods, only 53 percent of these records are seen as adequate
(Miret et al., 2009).

Suicide assessment in community mental health

Generally speaking, within the last ten years there has been a significant increase
in patients who receive care via community mental health clinics (Yoon et al.,
2013). Community mental health clinics refer to an agency, which provides men-
tal health services to individuals within a community who may not have the means
to afford it otherwise. These services are largely outpatient, but can include
 Formal assessment of suicide risk 209
inpatient wards (Bentley, 1994). A growing proportion of those with severe men-
tal illness are seen within these community-based clinics (Grob, 1992). Nearly
14 million individuals have received care in over 1000 community-based facilities
in the United States (Yoon et al., 2013). Professionals working in community
mental health encounter many of the same problems as those in larger hospital
settings. Specifically, staff in the same location attend differing training programs,
use different assessment strategies, and do not have a consistent definition of risk
(McAuliffe and Perry, 2007).
There is a paucity of research available on the assessment of suicide in com-
munity mental health. In Canada, however, there are particular benchmarks set
for health organizations. This research, summarized by McAuliffe and Perry
(2007), emphasizes the fact that a suicide assessment tool is not sufficient. They
have since instituted training programs for mental health professionals. Another
important aspect is that all professionals were given the same training protocol,
known as Applied Suicide Intervention Skills Training (ASIST). This program
focuses on enhancing clinicians’ comfort in therapeutic discussion regarding sui-
cide and self-harm (McAuliffe and Perry, 2007). This study showed that due to
these programs, there has been a reduction in hospital admission rates and the
length of hospital stays (McAuliffe and Perry, 2007). Farrow (2002) in a study of
New Zealand nurses, found the nurses tended to use suicide assessment tools,
such as No Suicide Contracts (NSCs), even when they are contraindicated. Many
nurses stated that they were never formally taught to assess for suicide and/or risk
(Farrow, 2002).

Implications
As evident through this review of the formal assessment of suicide risk in three
distinct mental health care settings, more research is needed regarding the
methods employed for suicide assessment. All three mental health care settings
are at great risk for suicidal clients. The rise in military and veteran suicides has
been well documented both in research and in the mass media. Additionally, due
to the difficulty in predicting suicidality, detailed research is necessary regarding
which assessment measures accurately predict risk in suicidal clients (Packman
et al., 2004). One option for further research is studying areas where there is a
distinct protocol which is consistently followed, such as the research created by
McAuliffe and Perry (2007). In the future it may be possible to determine
the success of these programs, as detailed by Miret et al. (2009). This will enable
researchers to determine which particular methods for suicide assessment are
effective in limiting false negatives.
Assessing suicidal risk can be difficult for even the most skillful clinicians. If
clinicians are not properly trained or well versed in the subject, they often fail to
ask pertinent questions and use client-friendly language. Suicide is often viewed
with stigma across cultures, and using blunt or accusatory statements may hinder
proper suicide assessment as well as the therapeutic alliance. Pragmatic approaches
in which the therapeutic alliance is used to approach the sensitive topic and the
210 Bruce Bongar et al.
use of collaboration and de-escalation lead to clinical outcomes in which the client
may understand the nature of their distress. Avoiding an adversarial and suspi-
cious tone and approaching suicidal ideation with curiosity, non-judgment, and a
calm-accepting demeanor may aid in developing a clinically accurate perspective
on the client’s level of functioning. Furthermore assessing a client’s functioning
using a diathesis-stress model may prove fruitful, as stressful life events often act
as an antecedent to suicidal ideation and behaviors. Utilization of formal tests to
evaluate a person’s likelihood of attempting or completing suicide remains
elusive, yet important discoveries continue to be made. The application of proper
training, baseline knowledge, adequate clinical interview, and integration of a
psychosocial history provides the best prognosis for an individual endorsing
suicidality. Although the practice may appear daunting, accurate risk assessment
provides a crucial role within mental health treatment as a whole.

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15 Culturally competent
suicide assessment
Uri Kugel, Lori Holleran, Kasie Hummel,
Joyce Chu, Peter Goldblum and Bruce Bongar

Cultural identity and suicidality

The concept of cultural identity is crucial for the focus of this chapter. Cultural
identity is an individual’s perception of their position in varying dimensions
of life such as race, sexual orientation, ethnicity, gender, religious belief, and age
(Tatum, 1997). Additional examples of cultural identity include subgroups such
as military veterans, college students, and people with disabilities. Due to the
multidimensional nature of one’s identity, one’s core sense of self and belief
system may be influenced by numerous factors at once. With regard to suicidality,
aspects of cultural identity could include symptomatic presentation, and risk and
protective factors. These various elements can be impacted in different pathways
dependent on the interaction between the cultural identity of the individual and
unique stressors existing in their life.
It is quite evident that there is great variety in suicide rates and risk factors
across cultural groups and individuals with different cultural identities (Chu et al.,
2010). In 2010, US completed suicide rates were the highest among American
Indians (25.85 per 100,000), followed by 25.65 for White males, 9.32 for Asian/
Pacific Islanders, 9.10 for African Americans, and 5.27 for Hispanics (Centers for
Disease Control and Prevention [CDC], 2010). When specifically considering
individuals who have served in the military, it is estimated that 22 Veterans com-
mit suicide per day, contributing to approximately 21 percent of the total
US suicide rate (Kemp and Bossarte, 2012).
While no national data is currently available regarding suicide rates in sexual
minorities within the US, a national registry study conducted in Denmark found
that among sexual minority males, suicide rates are nearly eight times higher, and
1.5 times higher in sexual minority females, relative to their heterosexual peers
(Mathy et al., 2011). Additionally, in a comprehensive literature review, an
increase in suicidal behaviors was seen among sexual minorities across the globe
(Plöderl et al., 2013). While risk is seen to vary based on group membership
related to both ethnic and other cultural factors, common suicide risk assessment
practices often lack systematic incorporation of these unique risk factors for sui-
cide (Chu et al., 2010). Some additional examples for such groups in the US
include Transgender people, Latina high school students, and African American
adolescent males.
214 Uri Kugel et al.
Suicidal ideation
Research has demonstrated that symptoms of suicidal ideation vary between
ethnicities, gender, and sexual orientation. Suicidal ideation is a critical symptom
of depression (American Psychiatric Association, 2000, 2013). However, as
data indicates, symptoms of depression can vary based on one’s cultural back-
ground. For example, in developing Eastern countries, such as Iran, speaking
about emotions is forbidden and seen as an indication of weakness (Seifsafari
et al., 2013). As a result, somatic symptoms (e.g., headache, irritability, and pain)
might be articulated instead (Tryon, 2008). The idea that certain emotional states
are substituted by somatic symptoms is based on a psychodynamic view and was
originally proposed by Freud (Tryon, 2008). However, more recently, stigmatiza-
tion and fear of appearing psychologically ill have been postulated as possible
reasons for this somatic manifestation (Dere et al., 2013). The expression of
emotional complaints through somatic symptoms is not unique to Eastern coun-
tries, it is also commonly found among Asian, Hispanic, and Latino patients
(Dere et al., 2013; Organista, 2008; Seifsafari et al., 2013; Zhou et al., 2011).
Unlike in western cultures, suicide in Japan does not carry with it any associ-
ation of shame or guilt (Kawanishi, 2008). On the contrary, it is commonly
utilized as a method of problem solving and is viewed as the highest form of apo-
logy for an unforgivable mistake. In a sense, taking one’s life to demonstrate
genuine repentance negates the individual’s mistake and restores honor to the
family. Even though this tolerant or even encouraging attitude toward suicide
within the Japanese culture is an ongoing obstacle for suicide prevention efforts,
suicide rates continue to be higher elsewhere in the globe (Kawanishi, 2008).
Furthermore, like Iranians, Japanese individuals are more likely to endorse
somatic complaints and to seek the advice of general practitioners (Waza et al.,
1999).

Suicide method
The choice of method in suicide has also been found to vary across cultural
groups. Means for committing suicide often differ across the globe due to social
acceptability and availability. In a study conducted by De Leo et al. (2013) in
which 14 different countries (the Commonwealth of Australia, New Zealand,
Philippines, Mongolia, French Polynesia, Hong Kong (two sites), Guam, Tonga,
Vanuatu, Fiji, Italy, China, and Brazil) participated, the preferred method of
suicide was hanging. Moreover, data indicated that more than 13 percent
of suicides in Fiji were attributed to fire and flames. In regards to nonfatal suicidal
behavior, overdosing on drugs, cutting, and poisoning were the most common
among the entire sample.
Furthermore, in 2004, over half of all suicides in Japan were completed by
individuals most likely to be affected by the financial recession, specifically middle-
aged men (Beautrais, 2006). In a work-centered society like Japan, karo-jisatsuor
‘suicide by overwork’ has been recognized as a societal issue (Kawanishi, 2008,
 Culturally competent suicide assessment 215
p. 65). A distinct characteristic of this method of suicide is the significant self-
blame that the individual feels regarding an inability to meet work demands
(as evidenced by suicide notes). In line with the Japanese view of suicide as a
method of problem resolution, individuals who engage in karo-jisatsu are
often attempting to save face. Lastly, in traditional China, hanging is the dominant
method because of the belief that the soul of the individual who dies by hanging
will return to Earth to plague the living, specifically those who caused harm
(Braun and Nichols, 1997). As a result, suicide by hanging carries with it the
association of wrath and vengeance.
According to De Leo et al. (2013), completed suicide across all countries
is more common among males; whereas nonfatal suicidal behaviors are more
common among females. Seifsafari et al. (2013) found related results among
an Iranian sample. Suicidal ideation was more common among females and
attempts were more common among males. Furthermore, both genders imple-
ment harmful behaviors that are consistent with their culture’s gender scripts
(De Leo et al., 2013). However, two exceptions to the gender pattern of suicide
have been demonstrated. The suicide rates in Fiji are equal between genders and
men in the Philippines engage in a higher rate of nonfatal suicidal behavior. In
regards to rate differences between age groups, past data from the World Health
Organization indicated that suicide is generally completed by middle-aged to
older individuals. Inconsistent with these findings, De Leo et al. (2013)
found that younger individuals in the Pacific Island countries were more likely to
commit suicide.

Risk and protective factors

Cultural identities such as ethnicity and gender are not necessarily the sole
influences on an individual’s beliefs about suicide. Risk and protective factors
that are unique to each cultural identity affect an individual’s belief system.
Gibbs (1997) found that religiosity, social support, old age, and residing in the
southern region of the United States were protective factors among African
Americans that could reduce the risk of suicide. Conversely, Rowell et al. (2008)
established that exposure to violence, being HIV positive, substance use, and
negative interactions with law enforcement were associated with an increased risk
of suicide for this same population.
Meyer et al. (2008) studied how social stress contributes to the overall stress
that an individual might experience. The social stress theory is a ‘framework as a
sociological paradigm that views social conditions as a cause of stress for members
of disadvantaged social groups’ (Meyer et al., 2008, p. 368). Their findings dem-
onstrated that consistent with the social stress theory, sexual orientation and
race/ethnic minority statuses are associated with an increase in overall stressors
and prejudice-related stressors. According to O’Donnell et al. (2011), risk factors
for suicide among African American and Latino lesbian, gay, and bisexual (LGB)
individuals include minority stress (prejudice, stigma, discrimination), family
rejection, early age of self-labeling, race/ethnicity, and gender-atypical behavior. In
216 Uri Kugel et al.
regards to protection against suicide for LGB individuals, a strong social support
system and a cohesive family can help decrease an individual’s level of vulnerabil-
ity to engage in suicidal behavior (Wilder and Wilder, 2012).

Suicidality assessment
Currently there are numerous measures utilized to assess for suicide risk including
the Scale for Suicide Ideation (SSI; Beck et al., 1979), which was subsequently
translated into the Beck Scale for Suicide Ideation (BSI; Beck and Steer, 1991),
the Beck Depression Inventory (BDI; Beck and Steer, 1987), the Beck
Hopelessness Scale (BHS; Beck and Steer, 1988), and the Suicide Ideation Scale
(SIS; Rudd, 1989). The SSI is a 19-item scale, scored from 0–2, assessing suicidal
thoughts and attitudes toward suicide, which originally were ascertained by a
clinician through a semi-structured interview, but was adapted into a self-report
measure during the transition into the BSI. The BDI is a self-report questionnaire
consisting of 21 items, scored from 0–3, assessing depression symptoms and
severity. The BHS is a self-report measure comprised of 20 true-false items,
examining hopelessness through pessimistic beliefs regarding the future. The SIS
is a self-report measure consisting of 10 items, scored upon a five-point Likert
scale, assessing suicidal ideation along a continuum ‘ranging from covert suicidal
thoughts to more overt or intense ideation and, ultimately, actual suicide attempts’
(Rudd, 1989, p. 175).
While these measures are widely regarded to be reliable and valid in assessing
risk within the majority population (Beck et al., 1979; Beck et al., 1990; Beck and
Steer, 1987; Beck and Steer, 1988; Luxton et al., 2011; Steer et al., 1993), there
is a paucity of information regarding their utility when assessing culturally diverse
populations. During the initial development and validation of the SSI, identifying
risk level was based mainly on psychological factors ‘as opposed to demographic
variables’ due to the belief that these variables lacked ‘practical utility’ in assessing
an individual’s suicide risk (Beck et al., 1979, p. 344). In a study seeking to
validate the use of the BHS and BDI within an outpatient population, neither
ethnicity nor other cultural factors, beyond age, gender, and diagnosis, were con-
sidered (Beck et al., 1990). While these assessment measures were found to be
suitable for use in assessing risk in an outpatient population, it is impossible to
ascertain how appropriate they are for use with culturally diverse populations.
In a study validating the use of the BDI, BHS, Beck Anxiety Inventory (BAI),
and SSI as a battery to assess risk in an outpatient setting, only the roles of gender,
age, and diagnosis on risk profiles were examined (Steer et al., 1993). While race
was recorded, its implications on risk were not investigated, and with 32 African-
American participants (2.7 percent) and 13 Asian participants (1.1 percent), out
of 1172 participants, it is notably uncharacteristic of the current broader popula-
tion (13.6 percent and 5.6 percent, respectively, US Census Bureau, 2010). More
recently a study examining risk factors in a non-clinical population, utilizing the
SSI, BHS, BAI, and BDI among other measurements, similarly recorded race but
failed to consider its influence on results (Brown et al., 2000). In addition to not
 Culturally competent suicide assessment 217
examining the specific findings related to minority participants, only a small
percentage of participants represented minority populations. Out of 6891
participants, 354 identified as African American (5.14 percent), 40 as Hispanic
(0.58 percent), and 27 as Asian (0.39 percent), which is substantially unrepre-
sentative of the current population demographics.
Considerable amounts of research have been conducted to validate these
widely used measures to assess risk, but the emphasis has remained on examining
their utility within majority populations. Yet, there is an abundant amount
of research recognizing that suicide risk factors are not constant across all
cultural groups, and that being a minority can itself be a factor related to risk
(Garrison, 1992).
To appropriately assess risk in culturally diverse populations it is imperative
that mental health professionals recognize unique factors that require examina-
tion to capture accurate risk levels. Culturally relevant themes have been seen
to influence risk in diverse populations (Chu et al., 2010; Goldston et al., 2008;
Joe and Kaplan, 2001; Langhinrichsen-Rohling et al., 2009; Meyer, 2013).
Yet, these themes are not specifically assessed for by any of the previously
identified measures and there appears to be no research specifically considering
the psychometric properties of these assessments for use within culturally diverse
populations.

Cultural theory and model of suicide

One reason for the lack of measurements specifically considering these factors may
be due to the fact that until recently these culturally relevant themes were not
easily distinguishable among the plethora of research examining specific aspects
regarding risk factors among cultural minority populations (Leach and Long,
2008). Without an existing comprehensive theory, assessing risk in cultural
minorities, including both ethnic and sexual minorities, could not be performed
in an accurate and consistent way (Lester, 2009). Yet, with the growing number
of individuals identified within minority populations, and the increasing rates of
risk seen in some of these groups (CDC 2009; Joe and Kaplan, 2001), the need
for a guiding theory was prominent (Leach and Long, 2008; Lester, 2009).
The cultural theory and model of suicide were created through a technique
utilizing the amalgamation of pre-existing data examining minority status and
suicide to identify overarching commonalities influencing suicide in cultural
minority populations (Chu et al., 2010). Specifically, risk factors associated with
African American, Asian American, Latino/a American, and sexual minority
(LGBTQ) groups were examined to guide the theory’s construction, with an
emphasis on identifying risk factors specific to each of the aforementioned
cultures. This included identifying ‘categories separate from simple minority
status as an ethnic or sexual minority individual; in particular, cultural factors are
defined to include beliefs, values, norms, practices, or customs held by ethnic and
sexual minority groups that have been shown to influence suicide’ (Chu et al.,
2010, p. 27).
218 Uri Kugel et al.
In total, 144 articles, published between 1991 and 2011, considering
suicide in cultural minority populations aided in the construction of this theory
(Chu et al., 2010). These articles provided 240 specific risk factors related to
suicidal behaviors within the four prior identified cultural groups. These specific
risk factors were then gathered into themes based on common attributes. Across
these four cultural minority populations (African Americans, Asian Americans,
Latino/a Americans, and sexual minorities (LGBTQ)), it was found that 228
of the 240 risk factors (95 percent) could be encompassed within one of four
culturally relevant themes:

Cultural sanctions
Cultural sanctions recognize specific suicide-related values, such as moral
protestations, related to the acceptability of suicide. Additionally it con-
siders attitudes, such as shame or acceptance, toward life occurrences that may
precipitate risk.

Idioms of distress
Idioms of distress consider variations in the probability that risk will be
communicated, how symptoms associated with risk are expressed, and how
suicide attempts may be manifested.

Minority stress
Minority stress examines the experience of cultural minorities based on levels of
acculturation, maltreatment, and social inequalities.

Social discord
Social discord considers how social, family, and community support influences an
individual. Specifically, identifying how conflict or estrangement impact level
of risk.
These themes construct a working cultural model of suicide. This two-part
model initially recognizes the role of life stressors in one’s ability or inability to
cope with exterior stressors (Chu et al., 2010). While both personal and social
stressors contribute to one’s life stressors, social stressors in particular have been
found to be quite influential for individuals identifying as cultural minorities
(Balsam et al., 2011; Huynh et al., 2012; Meyer, 2013). Social stressors encom-
pass three of the previously identified themes: minority stress, social discord, and
cultural sanctions. Additionally this model considers the role of cultural meaning,
which influences the model in two ways. First, it influences the way in which an
individual experiences life stressors based on their understanding of, or the
significance attributed to the event. In this regard, ‘the cultural sanctions
factor is particularly salient in the mediating mechanism of cultural meaning’
 Culturally competent suicide assessment 219
(Chu et al., 2010, p. 35). Second, it is seen to be a meaningful factor in one’s
decision to attempt or commit suicide (Chu et al., 2010). With regard to the act
of suicide, Cultural Meaning and Cultural Sanctions ‘determine whether one’s
tolerance threshold for distress is surpassed and ultimately whether a person acts
on suicide intention or impulse’ (Chu et al., 2010, p. 35). This model identified
by Chu et al. is also guided by three larger theoretical principles, consisting of the
themes and model factors previously discussed. The first principle is directly
associated with Idioms of Distress, and recognizes that culture influences how
suicidal thoughts and acts are expressed. This considers how culture impacts the
likelihood that one would reveal information regarding suicidal ideation or intent,
and the method of the suicidal action. The second principle is associated with
Cultural Sanctions, Minority Stress, and Social Discord. This principle recognizes
that culture influences suicidal behavior vulnerability based on the specific stres-
sors one encounters related to the culture to which they belong. In addition to
these specific cultural factors, it is imperative to recognize that other risk factors,
such as past suicide attempts and hopelessness, which are experienced across
majority groups, may also be present and impacting one’s overall experience of
suicidal ideation or intent. Finally, the third principle recognizes that cultural
beliefs regarding stressors and suicidal behavior influence the overall likelihood
of suicidal actions occurring (Chu et al., 2010). Taken together, these themes,
model, and overarching comprehensive theory provide a foundation for the
standardized examination of risk within cultural minority populations.

The Cultural Assessment of Risk for Suicide (CARS)

The Cultural Assessment of Risk for Suicide (CARS) is a 39-item self-report
measure for identifying culturally relevant suicide risk factors unexamined by the
previously identified suicide instruments. Due to the lack of parsimony in cultur-
ally competent risk assessment, Chu et al. (2010) created the ‘Cultural Model of
Suicide’ (p. 35), which attempted to address the risk and protective factors, as
well as cultural disparities in suicide among four diverse groups (LGBTQ, Asian
Americans, Latino/a American, and African American). Through a comprehen-
sive literature review Chu et al. scrutinized the attitudes, customs, prac-
tices, and standards of these cultures in order to demonstrate how they affect
suicidal behaviors. These factors were then organized into four aforementioned
categories: ‘Cultural Sanctions, Idioms of Distress, Minority Stress, and Social
Discord’ (Chu et al., 2010, p. 27). These four categories of the Cultural Model
of Suicide were then used to develop the CARS.
In order to test the psychometric properties of the measure, 950 participants
who were diverse in ethnicity and sexual orientation were recruited from colleges
and communities to complete the measure (Chu et al., 2013). In addition,
individuals were asked to complete the suicide item (Item 9) of the BDI, the SIS,
the BHS, and provide a lifetime history of suicide attempts, assessed through
Item 20 of the BSI, as a means for psychometric validation. A factor analysis was
conducted in order to distinguish the underlying factor configuration of the
220 Uri Kugel et al.
CARS scale. The result was an eight-factor solution including 39 items,
which accounted for 57.39 percent of total variance (Chu et al., 2013). Two
factors, Family Discord and Social Support accounted for the most variance
(28.25 percent). Convergent validity, determined by correlating the scores on the
CARS with other established measures of suicidal behavior revealed significance
at the p < 0.001 level. Furthermore, the overall CARS score demonstrated
superior internal consistency (a = 0.90; Chu et al., 2013).
The CARS measure provides numerous advantages over existing suicide
risk assessments. First, the CARS was constructed with cultural factors in
mind (Chu et al., 2013). In addition, it recognizes that a measure could not
incorporate every conceivable cultural disparity in suicide behavior and risk.
Furthermore, the CARS provides a method to recognize and categorize the
cultural distinction within suicide. Not only does the CARS have the prospect to
be used as a screening tool, it also has the capability to be utilized in the capacity
of prevention and management of suicide (Chu et al., 2013). It identifies critical
aspects of suicide risk that can be used to generate a culturally competent safety
and risk management plan.

Conclusion
Suicide rates and risk factors differ between cultural groups. An individual’s
cultural identity varies based on multiple facets that can impact core aspects of
their inner experience. A few of the many factors impacted include risk and
protective factors associated with suicide. Research has shown that varying
cultures maintain beliefs regarding suicide, express symptoms related to suicide,
and attempt to commit suicide in different ways from the majority population
found within the United States. While these discrepancies have been identified,
little emphasis has been placed on addressing and recognizing these differences
in regard to risk assessment.
Most widely used measures utilized to assess for risk focus on the symptomatic
presentation expressed in the majority population, which leads to uncertainties
regarding the accuracy of risk assessments being conducted in populations
including cultural minority group members. While research recognizes
differences in risk factors present in minority populations, how to assess for
these factors in a comprehensive way remained unclear until recently. The
Cultural Model of Suicide addressed these concerns through the systematic
examination of risk and protective factors associated with suicide among those
identifying as a minority group member (African American, Asian American,
Latino/a American, and LGBTQ), and constructed a measurement to accurately
assess for risk.
The CARS identifies four main themes encompassing the majority of risk
factors present within these groups. The themes include: Cultural Sanctions,
Idioms of Distress, Minority Stress, and Social Discord. The CARS is recognized
as a reliable and valid measure for identifying and categorizing risk within these
minority populations, with the ability to inform potential clinical decisions such
 Culturally competent suicide assessment 221
as treatment and safety planning. The full utility, both psychometrically and
clinically, of the CARS will continue to expand as the quantity of individuals
identifying as minority group members remains on the increase. In summary,
despite having some advances over the last few years and the development of a
measure such as the CARS, cultural assessment of suicide is still in its infancy and
requires continued research. Future research could examine the use of the
CARS with different minority populations, other countries, and languages.
Additionally, further support is needed for the use of the CARS in different
clinical settings or its use in standardized risk assessment procedures.

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16 Ethical and legal issues
in dealing with suicidal
behaviour
Swati Mukherjee and Updesh Kumar

The most common understanding of the term suicide is of an act leading to

termination of one’s own life. Suicide is the fatal outcome of an act that is
deliberately initiated and performed by the deceased him- or herself, in the know-
ledge or expectation of its fatal outcome, the outcome being considered by the
actor as instrumental in bringing about desired changes in consciousness and/or
social conditions (Retterstøl, 1993). Suicide is a universal human phenomenon
and a universal cause of concern across the globe. Every 40 seconds a human life
is lost to suicide somewhere in the world. Every year around 5 to 12 million
people die by suicide worldwide. A host of professionals across disciplines are
engaged in providing support services and care to suicide survivors and suicidal
individuals. Suicide is a social issue, a public health concern, or a result of mental
illness when viewed from the perspective of those who are entrusted with the
responsibility of preventing it. However, for the individual who takes the extreme
step of ending one’s own life, it marks a cry of pain, a cry for help, a desperate
attempt to get away from a situation one perceives uncontrollably painful, and
perhaps also a desperate attempt to achieve a desirable goal that is perceived as
unattainable otherwise. Even within the fraternity of helping professionals,
suicide may be defined differently depending on the purpose of the definition –
medical, legal, or administrative. Despite suicide being a universal cause of human
concern, it is a matter of perspective that provides a particular definition to an act
of self-inflicted violence. Such discrepancies of definition often get fore-grounded
in the discourses regarding perceived righteousness of a particular act by a group
contrasted with the opposite group ostracizing the same act as undesirable or
harmful. Simple examples might be given of the Japanese ‘Kamikaze pilots’ dur-
ing World War II who rammed their explosive-laden airplanes into the enemy
ships and of the Viet-minh ‘death volunteers’ post World War II who blew up
enemy tanks using long stick-like explosives-thereby causing huge damage to the
enemy, though losing one’s own life in the act. In recent times, the suicide bomb-
ers of the Western world see themselves as martyrs for the cause of their nations
or communities. Similarly, the contemporary debate about permissibility of
euthanasia or ‘mercy killing’ highlights the difference of perspective in consider-
ing the act as an act of compassion or of cruelty. Further it highlights the moral
dilemma involved in accepting the absolute right an individual has over his or her
 Ethical and legal issues 225
life, and death. Such a difference of perspective or philosophical stance is trans-
lated in the legislation formulated by different countries regarding euthanasia.
Society’s perspective on suicide is often influenced by and shaped through its
specific socio-historic circumstances, its value system, its religious beliefs and per-
ceptions about the meaning of human life. The self-sacrifice of wives on the death
pyre of the husband (Sati) or the customary mass suicides embraced by wives of
Rajput warriors when their husbands were out fighting their last battle (Johar)
are such practices that were prescribed by religious dogma and customs in India
in the Middle Ages. Alvarez (1971) mentions acts of suicide being viewed in a
positive manner in the warrior society of the Vikings, which believed a violent
death to be a mandatory prerequisite for attaining heaven. Ancient Greeks, on the
other hand, abhorred suicide and viewed suicidal behaviour negatively in general.
Though Plato allowed for some exceptional circumstances that could make sui-
cide morally acceptable, the general opinion of thinkers and larger society was
alike in condemning suicide by terming it as a cowardly act, and an act that
deprives the state of a citizen. Alvarez (1971, p. 58) links the extreme abhorrence
of the ancient Greeks to suicide to their ‘more profound horror of killing one’s
own kin. By inference, suicide was an extreme case of this, and the language barely
distinguishes between self-murder and murder of kindred.’ Though the specific
views and beliefs regarding suicide in these earlier ages hardly have a bearing on
the current practices and theoretical stances, these serve well to highlight the need
to keep the specific socio-historical milieu of a society in focus while prescribing
appropriate ways of dealing with suicidal behaviours.
Any ethical guideline or a legal code that deals with the complex issues
of suicide and suicide prevention needs to be cognizant and reflective of the
prevalent cultural-moral value systems of the society. Leenars and colleagues
(2000) provide a detailed discussion about the multiplicity and variation prevalent
in ethical and legal standards prevailing in different cultures regarding issues
pertaining to suicide. While recognizing that a comprehensive review of
multifarious issues involved is a difficult task, they nonetheless provide a broad
discussion about the ethical and legal issues involved in suicide and attempted
suicide, euthanasia and assisted suicide, standards of reasonable and prudent care,
responsibility for care, failure in care, liability and malpractice across a number of
countries and cultures. They emphasize, ‘ethical and legal standards are defined
according, first, to the standards of community practices, and second, to the
resources available and hence what can reasonably be expected’ (p. 434). Though
it is difficult to provide an inclusive code for care of suicidal individuals, a global
guideline could be drawn up based upon the basic principles of ethical practice in
counselling.
The profession of counselling is well regulated by professional organizations in
most countries. In their attempt to ensure ethical professional practice these
professional bodies enact and endorse ethical guidelines and norms, yet mere
awareness of ethical standards is neither sufficient nor adequate to answer the
ethical dilemmas that arise while dealing with clients (Bond, 2000). A counsellor
needs to develop a deep-rooted understanding of the cultural ethos and general
226 Swati Mukherjee and Updesh Kumar
ethical parameters of the society, and use these in designing the specific pathways
tailored to the needs of individual client.
Suicide, being the commonest psychiatric emergency, the role of a support
professional or a counsellor begins with accurate estimation of suicide risk and
adopting an appropriate management strategy based on the level of risk. Given
the commitment of their profession to human well-being, a counsellor must have
a deep and unwavering belief in the sanctity of human life that enables her to put
all her efforts towards its preservation and enrichment. In a way a counsellor must
be driven by the universal moral imperative of reducing suicidal risk. Yet, in
practice two core considerations remain – the moral status of suicide and the
morality of intervening to prevent suicide. The central question arising out of this
dilemma is of reconciling the premise of sanctity of human life with the right of
the individual over his or her own life.

The moral status of suicide

Through the ages philosophers have deliberated upon many dilemmas regarding
the act of taking one’s own life. These deliberations have involved core questions
regarding morality and rationality of suicide. Kagan (2007) distinguishes between
the two, first, if suicide could ever be considered as a rational act and under what
circumstances (the rationality question); and, second, if suicide could be con-
strued as a morally legitimate or a morally acceptable thing to do, and under what
circumstances (the morality question). There are varied opinions and analyses of
the issue, however, generally all thinkers have been opposed to grant any sanctity
to suicide on moral grounds. The arguments given for this range from theologi-
cally based doctrine of all life belonging to God, to the egalitarian argument of
sanctity of human life and dignity. A related argument is often raised, asking if the
human life is intrinsically valuable. Is life itself worth having? Kagan (2007) talks
about a range of propositions he terms as ‘container theories’ – neutral container,
valuable container or fantastic container, which draw the simile of human life to
a container. According to the neutral container theories, when evaluating the
worth of somebody’s life one needs to look only at the contents of life – life itself
is only a container that might hold good or bad content. Valuable container
theories propose that the very fact that somebody is alive is valuable. It adds
positive value to the balance of good and bad happenings or contents in one’s life.
Going further along the continuum, the fantastic container theories propagate
that the fact of being alive is so valuable as to be worthwhile in itself even when
the sum total of good and bad happening in one’s life end up on the negative side.
Accepting life as a ‘valuable container’ implies acceptance of a total sanctity for
life, without taking into consideration whether the actual living conditions are
facilitative of living. On the other hand, conceptualizing life as a ‘neutral con-
tainer’ entails that life is only as good as its contents, or the individual’s satisfac-
tion or dissatisfaction with the life conditions. It has been a matter of perpetual
contemplation and deliberation for thinkers across the ages what it actually means
to live. Is life merely constituted of biological existence or has it a deeper
 Ethical and legal issues 227
meaning? For example, when a person feels grateful for ‘merely being alive’, does
she actually mean so, or does she presume the presence of certain conditions and
factors that enrich her life and well-being?

The meaning of life: a psychological perspective

‘What does it mean to be alive?’ ‘What makes life valuable and worth living?’
These and many such questions pertaining to the essence of life have always
intrigued the thinkers and philosophers of Eastern and Western societies alike.
Explanations range from theological doctrines to modern-day biological and
evolutionary explications. In modern times ‘meaning in life’ has been an important
construct for the psychologists too, though they frame the question in a slightly
different manner by asking ‘When and how does one experience a sense of
fulfilment and well-being in life?’ or ‘What does it take to ensure one’s subjective
well-being?’
There are variety of definitions and varied paths to achieve meaning in life. The
main components that can be discerned from these definitions are: a sense of
coherence in one’s life (Battista and Almond, 1973; Reker and Wong, 1988); goal
directedness or purposefulness (Ryff and Singer, 1998); or sense of commitment
(Thompson and Janigian, 1988). Wong (1998) emphasizes that an individual
derives sense of meaning in life by appraising oneself in the socio-cultural context
(cognitive component), that in turn provides one with satisfaction and fulfilment
(affective component), and motivates one to strive for valuable goals (motiva-
tional component). As Frankl (1965) says, since there cannot be any universal
meaning of life to fit all, it is a subjective and individual pursuit for the individual
to cultivate meaning in life. Frankl (1963) argues that humans are driven by
an innate need to find meaning in life (‘will to meaning’) and a situation of
existential vacuum, which could arise as a result of a sense of complete emptiness
and an absence of purpose for continuing to live, leads to ‘loss of meaning’
(Frankl, 1967). Such experiences of loss have been found to trigger feelings of
despair, chronic anxiety, depression, addictions and also suicidal behaviours
(Debats et al., 1993; Harlow et al., 1986). On the other hand, having more
meaning in life has been found to correlate with happiness and well-being
(Chamberlain and Zika, 1988; Debats et al., 1993).
Meaning in life has especially been an important construct in the field of
humanistic psychology and in the recent years in positive psychology. Humanistic
psychology began as a movement in the late 1950s and the early 1960s against
the deterministic and negative view of individual life and psyche. Humanists
restored the agency and dignity of individuals by emphasizing that the individual
be seen and analysed holistically, and be acknowledged as a worthwhile person
beyond genetic or environmental endowments. With Abraham Maslow and Carl
Rogers as helm bearers, the humanists emphasized that individuals’ behaviour is
determined by their subjective perceptions and personal meanings they attribute
to these; and that each individual is intrinsically motivated to strive and fulfil their
inherent potential. Despite the early differences that positive psychology had with
228 Swati Mukherjee and Updesh Kumar
the humanist movement, and despite standing on different epistemological and
methodological ground, the fundamental propositions made by the positive psy-
chol-ogy movement apparently match seamlessly with its predecessor (Schneider,
2011). The positive psychology movement was initiated by Seligman and
Csikszentmihalyi (2000), with a proclamation ‘psychology of positive human
functioning will arise that achieves a scientific understanding and effective inter-
ventions to build thriving in individuals, families, and communities’ (p. 5), with
a focus on recognizing and building upon the inherent potentialities of the
individuals in order to help them attain happiness, fulfilment and well-being.
They conceptualized positive psychology initiatives resting on three conceptual
foundations: positive subjective experiences, positive traits and positive environ-
ment. Apparently, both humanistic and positive approaches delve into the issue
of meaning of human life beyond the hedonistic conceptualizations of pleasure-
pain, and endorse the eudemonic constructions that emphasize personal growth
and cultivation of psychological strengths as the path to attain fulfilment and
well-being.
Humanistic perspectives have made a vast impact not only on the discipline
of psychology, but on the wider culture and society too. One of the seeds sown
by the movement has led to the foundation of the profession of counselling and
shaped the contours of client-centred approaches by recognizing the all-
important role of ‘self ’ in alleviating distress and instilling a drive towards
fulfilment and actualization of potentials. In a way, the humanistic approach has
influenced the research and practice of psychology by providing a unique per-
spective to human life that informs and enlightens the path of psychology
professionals. Both positive and humanist approaches look beyond the medical
model of psychology and emphasize efficiencies over deficiencies. A therapist or
counsellor hence does not merely aim at mitigating crisis, but seeks to build a
supportive environment where the individual feels free to share his/her lived
experiences, and through empathetic listening nurtures and strengthens the
positive potentials lying dormant within the individual. Such a conceptual and
theoretical grounding leads to easy enunciation of an ethical framework for
professionals supporting individuals in distress.

Ethical issues in providing support services

to suicidal individuals
Etymologically, the term ethic derives from the Greek ‘ethos’, meaning habits or
customs. However, ethics have come to connote something more than mere
habits or customs. Ethics are those standards of behaviour that a group or society
prescribes for its members and expects them to adhere to these in a normative
manner. In setting the normative standard of behaviour, the ethics prescribed by
a group, organization or society set an evaluative norm that actively discriminates
the desirable from undesirable and offers value-based judgements on the accept-
ability of behaviour. Leong et al. (2008) define ethics as ‘the agreed upon stand-
ards of aspirational and mandatory behaviours and practices’ (p. 182). Ethics set
 Ethical and legal issues 229
an aspirational standard of behaviour in a manner that distinguishes the malum
in se (bad in itself) from malum prohibitum (wrong only because law prohibits it).
This implies an ethical code subsumes any legal codes on a given issue, and
demands a moral virtue of compliance even in the absence of fear of being repri-
manded. The key attribute that place ethics on a higher level than the law is the
freedom of choice – choice that one makes in adhering to good and refraining
from bad even in the absence of a binding authority.
Being able to distinguish the good from bad on one’s own volition and
deciding an appropriate course of action, thus appears to be the core competence
any support professional must strive to inculcate, in order to deal with the
individuals facing a crisis, including suicidal behaviours. This is not an easy task to
accomplish, as there cannot be a straightforward prescription of dos and don’ts.
A support professional needs to actively listen to the individual in crisis, infer the
hidden meanings, assess the issue at hand and design an intervention strategy to
ensure optimum welfare of the person.
Fisher (2009) describes the general principles that form the basis for constitut-
ing the ethical standards in the profession of counselling. Though these are gen-
eral ethical principles for the helping professionals, these set an aspirational
standard that they must strive to achieve in order to fulfil the professional goals
of welfare and beneficence.
The first principle, that of Beneficence and Non-maleficence reiterates the need
to maintain a balance between the dual roles played by a psychologist or support
professional while providing support services to a distressed client – providing
benefits in the best interest of the client, at the same time avoiding harm to the
client. Beneficence implies a duty to improve the conditions of others through the
use of one’s professional knowledge and wisdom. A support professional benefits
a client by structuring all intervention keeping the client’s welfare as primacy. The
clause of ‘non-maleficence’ puts the onus on the support professional to avoid or
minimize any harm to the client. Originating from the Hippocratic Oath, the
principle of non-maleficence calls for avoiding all acts that can potentially harm
the client, and directs to minimizing the effects in case any harm has been caused
inadvertently or under unavoidable circumstances.
The second ethical principle concerns with Fidelity and responsibility. Fidelity
implies faithfulness of one human being to another (Ramsey, 2002). This includes
keeping one’s words, discharge and acceptance of responsibilities and maintenance
of relationships including scientific, professional and teaching relationships. A
support professional must realize the importance of providing intervention to
individuals in crisis and the responsibility it entails. In keeping with the sanctity
of such a role, they need to adhere to a high standard of professional competence
and ethical fidelity in their work. Gardener (2012) enumerates the ethical
behaviours that mark the principle of fidelity for the professionals working for
suicide prevention. These are: (a) the responsibility to keep promises and
contracts; (b) to perform duties in a responsible manner and avoid actions that
violate the ethical standards; (c) being trained in current methods of treating
suicide ideation and behaviours; (d) not being silent when it comes to the safety
230 Swati Mukherjee and Updesh Kumar
of the client; (e) not using deceptive practices or encouraging deception in others;
and (f) maintaining confidentiality and allowing the client to know when
confidentiality is not possible and/or what the limits might be. The principle
of fidelity serves the crucial function of cultivating a trusting relationship
between the distressed individual and the support professional that facilitates a
comprehensive exploration of suicidality.
The third ethical principle, closely related to fidelity is of maintaining absolute
Integrity. Integrity implies honest communication, telling facts as it is to the client
and also keep the commitments made to the clients.
The fourth principle concerns ensuring equitable Justice to all clients. This
means that the counsellor is obliged to treat all individuals with care and
consistency, not discriminating on the basis of socio-economic status, role or
religion, and to guard against his/her own inadvertent prejudices in providing
care to the clients. This also implies that the policies, procedures and norms for
providing care to suicidal individuals must provide a consistent method of
identification and treatment.
The fifth principle of ethical conduct put forth by Fisher is about ensuring
Respect for People’s Rights and Dignity. This implies being aware of cultural
sensitivities of the client and respecting the race, ethnicity and religion of the
client. The counsellor needs to be competent enough to understand the choices
made by the client and the limits placed by such subjectivities. An ethical mandate
for ensuring the right and dignity of the distressed individual makes it essential
for the counsellor to determine what and how much of personal information is
essential to be shared for the purpose of therapy (Fisher, 2009).
Beauchamp and Childress (1979) and Gardener (2012) add another important
dimension to the ethical considerations – that of the autonomy of the client to
make decisions regarding health options, and right of self-determination in order
to preserve one’s dignity.
This places an obligation on the counsellor or the support professional to
provide all the relevant information to the client in order to help her make an
informed decision regarding various issues, like consent for disclosing infor-
mation, consent for receiving medication, consent for referral or hospitalization
and any other issue concerning her welfare. Explicating the principle of autonomy
of the client, Gardener (2012) emphasizes that among all other information the
counsellor must include and explain to the client the ‘information regarding
suicide and how it is a choice resulting from a psychological breakdown of
defences and increased vulnerability’ (p. 28).
This gets one back to the core dilemma in the case of suicidal individuals – the
dilemma between providing autonomy to the client on one hand and commit-
ment for ensuring beneficence of the client on the other. The premise on which
autonomous decision-making by the client rests is informed consent. However,
the circumstances and psychological conditions leading a person towards suicidal
behaviours also limit the repertoire of choices available to the person to make
autonomous informed decisions. Simply put, mental illness or psychological
distress often compromise informed consent. Given the ethical guideline of
 Ethical and legal issues 231
beneficence and non-maleficence, it might be even simpler to assume the role of
a paternalistic protector of the client’s life from the damage that he/she can cause
to him/herself. However, as Gardener (2012) asserts, the resolution of the
dilemma between autonomy and beneficence lies in structuring the support in a
manner that it works to restore autonomy in a positive manner and strengthens
the resources of the person in order to improve coping. It might be asserted that
in many cases it is escaping from a painful situation, and not death per se, that
pushes the suicidal individual towards taking the fatal step. It is not impossible
to dissuade the suicidal person from ending one’s own life, if the support
professional succeeds in helping him visualize the possibility of other solutions,
thereby alleviating helplessness.
Another core issue of practical concern that emerges when dealing with suicidal
individuals is of the dilemma between commitment to maintain con-
fidentiality and minimize harm to the client. Relying on the trust built in a thera-
peutic relationship the distressed individual might reveal a history or prob-
ability of suicidal behaviours, and the counsellor might be left with making the
difficult decision of sharing the information with the family of the client or
honouring the confidentiality code and keeping mum. Dilemma deepens when
there is a legal obligation to share information with appropriate agencies, or when
the law of the land views suicide as a culpable act or even as a punishable
crime. These are difficult situations and there cannot be any straightforward
answers, however, with an in-depth understanding of the case and an unshaken
commitment to ethical behaviour, the counsellor needs to figure out the solution.

Resolving the legal issues

There is a wide variation across nations and cultures in the manner the act of
suicide is viewed from the legal perspective. While most Western countries have
decriminalized the act, many nations of the Global South continue to penalize
suicide attempters. Notwithstanding the age-old cultural taboos and prohibitions
that continue to impact societal views about suicide, it is quite ironic that a dis-
tressed individual who attempts to extinguish one’s own life, presumably due to
extreme hopelessness and despair, is viewed as a criminal by the society and its
legal system, and put behind the bars, instead of being provided care and support.
It is ironic too that criminalization of the act and fear of punishment fail to deter
the suicidal individuals from attempting the act. There are five widely accepted
purposes that criminal legislation purports to achieve through prescribing punish-
ments, these are: retribution, deterrence, incapacitation, rehabilitation and res-
toration. In criminalizing suicide and prescribing a punishment for attempting the
act, the law attempts (and usually fails) to coercively attain only two of these five
purposes, those of deterrence and rehabilitation. Apparently, a legal code that
criminalizes suicide views it as deadly violence against the self and not as a mental
health issue, meriting any supportive intervention for deterrence. It has been
proposed that the law of the land is reflective of the general ethos of society, and
keeps evolving as a result of historical forces, scientific-medical evidence, and
232 Swati Mukherjee and Updesh Kumar
political change. The wider ethos is usually shaped by the ruling or dominant
classes of the society that determine whether a particular act or behaviour be
considered harmful and criminalized. Given the influence of historical forces and
socio-cultural circumstances, the act of suicide has been proscribed or prescribed
under varying circumstances and in varied contexts. In certain circumstances
intentional behaviour leading to extinguishing of one’s life is even termed differ-
ently and eulogized as ‘self-sacrifice’, ‘martyrdom’, or a moral duty towards one’s
religion, society, or nation. The issue of societal and legal prescriptions regarding
suicidal behaviours also brings into focus the philosophical debates regarding
individual autonomy, free will and right over one’s own life. Indian law on suicide
and the way it has been interpreted by the highest court of law of the nation
provide an interesting case for discussing the issues of sanctity of life and right to
live juxtaposed with the right to die.

Suicide legislation: the case of India

India continues to be one of the few nations that criminalize the self-harm behav-
iours. Though suicide is not listed as a crime, the legal provisions in India make
attempted suicide an offence punishable under Indian Penal Code. The relevant
section reads thus: ‘Whoever attempts to commit suicide and does any act towards
the commission of such offence shall be punished with simple imprisonment for
a term which may extend to one year or with fine, or with both.’ This legal provi-
sion has been contrasted with the overriding constitutional provision of ‘Right to
life’ (Article 21 of the Constitution of India) that guarantees the right to life as a
fundamental right to all the citizens. Article 21 of the Constitution provides for
protection of life and personal liberty and reads thus: ‘No person shall be deprived
of his life or personal liberty except according to procedure established by law.’
The Right to life as enshrined in the Constitution has been interpreted liberally
in many landmark cases by the Supreme Court of India and has led to the
conceptualization of life as definitely meaning much more than mere biological
existence or survival. Various rights have been held to be covered by Article 21;
such as right to go abroad, right to privacy, right against solitary confinement,
right to speedy trial, right to shelter, right to breathe in an unpolluted environment,
right to medical aid, right to education, etc. (Maneka Gandhi v. Union of India,
AIR 1978 SC 597). At a particular juncture it has also been interpreted by the
apex court that the right to live brings in its trail the right not to live a forced life
(P. Rathinam v. Union of India, AIR 1994 SC 1844), and accordingly the act of
suicide stands decriminalized. However, further deliberations in another case
(Gian Kaur v. State of Punjab, AIR 1996 SC 946) have led the apex court to lay
down the position that the ‘Right to life’ cannot be construed to include within
it the ‘right to die’. Explaining the fundamental opposition of death with life the
apex court observed that right to life includes right to live in a dignified manner,
though not a right to end one’s life.
As to date India remains one of the very few nations that criminalize suicide.
The Law Commission of India tasked with a periodic review of the legislative laws
 Ethical and legal issues 233
makes a recommendation in its report (2008) of decriminalizing suicide by
repealing the relevant section (Sec. 309 Indian Penal Code) of the criminal law.
In their report they enumerate the difficulties that arise in preventing suicide
merely because it is a criminal act. Quoting from the report:

Emergency treatment for those who have attempted suicide is not readily
accessible as they are referred by local hospitals and doctors to tertiary centers
as it is termed as Medico Legal case. The time lost in the golden hour will
save many lives. Those who attempt suicide are already distressed and in
psychological pain and for them to face the ignominy of police interrogation
causes increased distress, shame, guilt and further suicide attempt. At the
time of family turmoil dealing with police procedure adds to the woes of
the family. It also leads to a gross under-reporting of attempted suicide
and the magnitude of the problem is not unknown. Unless one is aware of
the nature of extent of the problem, effective intervention is not possible. As
many attempted suicides are categorized in the guise of accidental poisoning
etc. emotional and mental health support is not available to those who have
attempted as they are unable to access the services.
(pp. 34–35)

Concluding comments
Suicide is an individual act, yet the antecedents and consequences of the
act concern the entire society. Beginning with socializing the individual in a
particular manner, making one accept and internalize the social mores and values
in general and the value of a human life specifically, the society structures
the individual in all aspects. Going beyond viewing suicide merely as a mental
health issue, the role societal values and cultural prescriptions can play in its
prevention becomes evident. A culture tolerant of suicidal behaviour, a society
normalizing a particular form of suicidal behaviour, or a religious dogma
eulogizing specific forms of suicide provide a potent ground for suicidal behav-
iours. Further, a legal framework that attempts to prevent suicide through
criminalizing the act, thereby squarely holding the individual responsible for the
wrong done, summarily absolves the society of any responsibility for creating and
providing minimum conditions that make a dignified existence possible for the
individual.
A support professional working for suicide prevention has to trudge through
this minefield in the course of his/her daily work. The task of alleviating
distress might prove to be immensely rewarding, but at the same time immensely
challenging. Despite the availability of elaborate professional guidelines and legal
advisories the counsellor needs to consider each situation on its own merit,
giving due credit to its specificities and an empathetic understanding of the
needs of the client. A multi-dimensional perspective along with professional
competence are the handy tools a counsellor must rely upon in order to enable
ethical decision-making.
234 Swati Mukherjee and Updesh Kumar
At the group level, a body of professionals working for suicide prevention and
mitigation needs to articulate the ethical stance relied upon and work to bring in
positive interventions not only for the distressed individuals, but also at the
societal level, striving to make the social environment suited for a fulfilling and
thriving human existence.

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Index

Locators shown in italics refer to figures and tables.

5-Ht receptors: influence on suicidal behaviours 27

abuse, alcohol: and suicides in Eastern assessment, suicidality: critical client

Europe 171–6; disease and mortality features requiring 203–4; definition
attributed to in Eastern Europe 170–1; 202; implications for practice 209–10;
implications for government policies importance of assessment of formal risk
181; public health interventions to ease 202–3; in community mental health
suicide from 176–81; significance as 208–9; in non-veteran hospitals 207–8;
cause of suicide 168–9 in Veteran’s Affairs hospitals 206–7; of
access, restrictions: to means of suicide client strengths and vulnerabilities 205;
as therapy 17–18 of history of suicidal behaviours 204;
adoption: studies of suicide patterns of risk factors for self harm 205; of
among 23–5 suicide risk, based on assessment
adversity, social: impact on suicide rates location 206; tools enabling 216–17;
98–9; see also outcomes e.g. exclusion, see also behaviours, suicidal; risk, formal;
social; isolation; stress, psychosocial; see also factors impacting e.g. culture;
vulnerability, suicidal see also particular tools e.g. cultural
aggression: interchangeability with assessment of risk for suicide
impulsivity 67–8; psychopathy of and Atha, C. 15
suicidal behaviours 71–3 attempts, suicide: definition and
Air Force personnel see personnel, incidence 66; influence and psychopathy
military of aggression 71–3; influence and
Akiskal, H. 43–4 psychopathy of impulsivity 68–71;
alcohol: contributional role in suicide in rates and likelihood among LGB
former USSR 94; disease and mortality youth 123
attributed in Eastern Europe 170–1; austerity, economic: role in suicide in
extent of consumption in Eastern former USSR 90, 91–2, 94
Europe 168; see also abuse, alcohol
Alvarez, A. 224 Baca-Garcia, E. 70
Anestis M. 57, 59–60 Baechler, J. 7
antisocial personality disorder 48–9 Bagian, J. 208
Applied Suicide Intervention Skills Bandura, A. 10
Training (ASIST) 209 Barrett Impulsiveness Scale 68–9
Apter, A. 47 Basu, S. 98–9
Arensman, E. 114 Baumeister, R. 7, 10–11, 56
Armstrong, M. 15 Beauchamp, T. 230
army personnel see personnel, military Beautrais, A. 110–11, 114–15
 Index 237
Beck Depression Inventory (BDI) 141, Browne, T. 5
216 Bryan, C. 155
Beck Hopelessness Scale (BHI) 216
Beck Scale for Suicide Ideation (BSI) cardiovascular disease: impact of stress on
216 in former USSR 90–4, 92–3
Beck, A. 10 Caspi, A. 28, 29–30
behavioural approaches: to mental disorder catechol-O-methyltransferase (COMT):
therapy 14–17; see also programmes of effect on suicidal behaviours 28
e.g. centres, suicide prevention; quick Center for Disease Control and Prevention
help interventions 204
behaviours, suicidal: definition, context centres, suicide prevention 16
and interpretations 224; impact and Chamlin, M. 173
influence of media representations of change, economic: role in suicide in
186–96, 188, 189; impact of genetics former USSR 90, 91–2, 94
25–32; impact of psycho-social stress in Cherpitel, C. 169
triggering 82–94, 81, 83, 86–7, 88–9, Childress, J. 230
92; need for standards and guidelines Chotai, J. 114, 115
225; prevalence and incidence 136, Chu, J. 217, 218–20
138–9; protective factors preventing Clemans, T. 155
206; role of mental disorders as Cloninger, C. 42–3, 44
exacerbating in Hungary 143–6; clusters and clustering, suicide: definitions
significance of history of for assessment 110–11; epidemiology 112; importance
204; situations driving 98–100; see also of strategic and coordinated responses
assessment, suicidality; attempts, suicide; 116; risk factors associated with 113–15;
suicide and suicidality; vulnerability, role of media coverage in determining
suicidal; see also considerations e.g. ethics 112–13; see also contagion, suicide
and morality; law and legislation; Cockerham, C. 179
see also factors affecting e.g. aggression; Cohen, M. 208
impulsivity; see also particular e.g. combat, exposure to: impact on suicide of
ideation, suicide; self-harm USA military 155–6
Bellivier, F. 26 community based approaches: to mental
‘Big three’ dimensions of personality disorder therapy 16
(Eysenck) 41–2 Connor, K. 72
Bielinska-Kwapisz, A. 172 consumption, alcohol see alcohol
Binczycka-Anholcer, M. 171 contagion, suicide: definitions 111;
biology: as theory and explanation for importance of strategic and coordinated
suicide 9 responses 116; risk factors associated
bisexuals, youth see youth, lesbian, gay and with 113–15; role of media in
bisexual determining prominence of 112–13;
Blüml, V. 40–1 see also clusters and clustering, suicide
Bolling, D. 102 Corticotropin-releasing hormone (CRH):
Bondy, B. 27 effect on suicidal behaviours 29
Bongar, B. 46 countries, former USSR: impact of stress
Borderline personality disorder (BPD): on health in former USSR 90–4, 92–3;
influence on suicide susceptibility 46–7; prevalence and patterns of suicides in
significance of emotion dysregulation 82–90, 83, 86–7, 88–9; significance of
58–9; significance of aggression in micro-, meso- and macro-stress in
suicidal behaviours 72 80–1, 81
Bostwick, J. 207 Coutts, A. 98–9
Box, G. 172 crises, socio-economic: impact on suicide
Boyce, N. 110 rates 98–9; populations at risk of suicide
Brent, D. 24 99–100; role in suicide in former USSR
Brezo, J. 30, 40 90, 91–2, 94; see also interventions,
Brodsky, B. 72 crisis; see also outcomes e.g. exclusion,
238 Index
social; isolation; stress, psychosocial; Eastern Europe: disease and mortality
vulnerability, suicidal attributed to alcohol 170–1; extent of
Csikszentmihalya, M. 228 alcohol consumption 168; implications
culture: and suicide and suicidality for policies of alcohol abuse and suicide
213–16; impact of military on suicide 181; interventions to ease suicide from
among USA military 156–8; influence alcohol abuse 176–81; suicide attributed
on media representation of suicide to alcohol abuse 171–6; suicide rates
191–3; models and theories of suicide 169–70; see also countries e.g. Hungary
217–20 ecology, of media: influence on media
Cultural assessment of risk for suicide representation of suicide 193–4
(CARS) 219–20 economics: impact on suicide rates 98–9;
Cyders, M. 67 populations at risk of suicide 99–100;
role in suicide in former USSR 90,
Daine, K. 113 91–2, 94; see also outcomes e.g. exclusion,
Davidson, L. 115 social; isolation; stress, psychosocial;
De Leo, D. 8, 70, 214, 215 vulnerability, suicidal
De Luca, V. 26, 29 Egeland, J. 24
Denneson, L. 206–7 elderly: impact of fact of on suicide
depression: etiology and prevalence among decisions 215–16; isolation of as
LGB youth 126; see also major significant for social crises 99–100
depressive disorder Emotion Regulation Group Therapy
Dialectical Behavior Therapy (DBT) (ERGT) 57
57, 61 emotions, dysregulation of: definition and
discord, social: significance for suicide and relationship with suicidality 56–62
suicidality 218–19 environments: impact on suicidal
disease and mortality: attribution in behaviours 29–30
Eastern Europe to alcohol 170–1; Ernst, C. 31
stress as driver resulting in 90–4, esteem, self-: influence on suicide
92–3; see also suicide and suicidality; susceptibility 44–5
see also particular e.g. cardiovascular ethics and morality: moral status of
disease suicide 227–8; need for standards and
disorders, mental: aims of crisis guidelines vis a vis suicide 225; of
intervention, 14; approaches and support for suicidal individuals 228–31;
characteristics of therapy for 14–18; see also law and legislation
role in exacerbating suicidal behaviours ethnicity: impact on suicidal ideation 214;
in Hungary 143–6; see also services, impact on suicide method 214–15
community; see also specific e.g. Europe, Eastern see Eastern Europe
depression; posttraumatic stress European Health for All Database
disorder; see also type e.g. medically (EHAD, WHO)
serious suicide attempters; personality exclusion, social: significance for suicidal
disorder; posttraumatic stress disorder vulnerability 101–2; therapeutic action
distress, idioms of: significance for suicide to alleviate 103; see also isolation, social
and suicidality 218 exposure, combat: impact on suicide of
distress, minority: significance for suicide USA military 155–6
and suicidality 218 Eysenck H. 41–2
Doihara, C. 72
Dori, G. 44–5 families: recommendations to maximise
Dumais, A. 69, 71 LGB youth protection from suicide
Durkheim, E. 5, 7, 12–13, E. 98, 99, 131; studies of suicide patterns among
178 23–5; see also relationships, family
Dwivedi, Y. 29, 31 Family Acceptance Project (FAP, USA)
Dwyer, R. 193 129
dysregulation, emotion: definition and Farrow, T. 209
relationship with suicidality 56–62 Finno-Ugrian Suicide Hypothesis 138
 Index 239
Fisher, C. 229, 230 heart disease: impact of stress on in former
Fluid Vulnerability Theory (FVT) of USSR 90–4, 92–3
military suicide and suicide mode 158–9 Hegerl, U. 112
Frankl, V. 227 Heisel, M. 40, 41
Freud, S. 5, 9–10 Henry, C. 44
Fudalej, S. 26 Hesselbrock, V. 30
Hetzel, B. 16
Galfalvy, H. 26, 31 Ho, L. 28
Gardener, G. 229, 230, 231 hospitals: suicidality assessment in non-
Garvey, M. 48 Veteran 207–8; suicidality assessment
Gay, Lesbian and Straight Education in Veteran’s Affairs 206–7
Network (GLSEN) 127 Hufford, M. 168
Gay-Straight Alliances (GSAs) 129 Hume, D. 9
Gays, youth see Youth, lesbian, gay and Hungary: geographical and temporal
bisexual variation of suicides 140–2; prevalence
gender: impact on stress and suicide in and incidence of suicides 138–9; role of
former USSR 87–90, 86–7, 88–9, 91–2, mental disorders as cause of suicidal
92, 93–4; impact on suicidal ideation behaviours 143–6
214; impact on suicide method 214–15
genetics: future prospects for genetic ideation, suicide: impact of culture on 214;
impact studies 30–1; impact on suicidal rates and likelihood among LGB youth
behaviours 25–30 123
Genome Wide Association Studies ideology see politics and ideology
(GWAS) 30–1 Ikunaga, A. 192
geography: impact of variation in on illness, mental see disorders, mental
suicides in Hungary 140–1; impact on Immediate Memory Task (IMT) 67
distribution of suicides 137–40, 139 impulsivity: interchangeability with
Ghanem, M. 69 aggression 67–8; psychopathy of and
Gibbons, J. 16 suicidal behaviours 68–71
Gibbs, J. 215 incidence and prevalence: suicides,
Ginter, E. 81 attempted suicide and suicidal
Gould, M. 110 behaviours 3, 39, 66, 82–90, 83, 86–7,
governments, policies of: implications for 88–9, 136, 138–9, 153–4
of alcohol abuse and suicide 181 injury, non-suicidal self-: significance of
Grünewald, P. 174 emotion dysregulation 59–60
guidelines and standards: need for vis a vis ‘Integrated Motivational-Volitional’ (IMV)
suicide ethics 225 model 11
Gut-Fey, A. 68 Interpersonal-Psychological Theory of
Suicidal Behaviour (IPTS):
Haney, E. 207 characteristics and impact of emotion
harm, self-: assessment of risk factors for dysregulation 57–8, 59–62
205; correlation with peer victimisation interventions, crisis: aims and
and suicide of LGB youth 126–7; characteristics 14; see also therapies; see
see also non-suicidal self injury also types e.g. Quick help interventions
Hatzenbuehler, M. 125 interventions, public health: to ease suicide
Haw, C. 115 from alcohol abuse 176–81
Hawton, K. 16, 70, 112 intoxication, alcohol see abuse, alcohol
health: stress as driver impacting on isolation: significance as driver for social
90–4, 92–3 crisis 99–100; see also exclusion, social;
health, public: interventions to ease suicide see also outcomes e.g. vulnerability,
from alcohol abuse 176–81 suicidal
healthcare: impact of professionals on
preventing LGB suicide 129–30 Jenkins, G. 172
Heard, H. 15 Joiner, T. 11, 57, 70–1, 99
240 Index
Jones, P. 113 Mehlum, L. 46
Joshi, H. 42 Menninger, K. 10
Meyer, I. 215
Kagan, S. 226 Michaelis, B. 72
Kant, I. 9 Mielicka-Kubein, Z. 172
Kelly, T. 47 military personnel see personnel, military
Kia-Keating, B. 28 Miret, M. 208, 209
Kim, B. 29 Mitrev, I. 71
Kinderman, P. 9 models and theories: of attachment
Kleinman, K. 110 101; of impact of culture on suicide
Kochman, F. 44 217–20; of suicide 9–13; personality
Kölves, K. 171–2 and tendency to suicide 40–2;
Kopp, M. 81 relationship of emotion dysregulation
Kumar, U. 42 and suicidality 57–62; stress
vulnerability 105; see also name e.g.
Ladwig, K. 112 Fluid Vulnerability Theory
Landberg, J. 175 Monoamine oxidase (MAO): influence on
Larkin, G. 110–11, 114–15 suicidal behaviours 28
law and legislation: resolving legal issues Monteith, L. 154
around suicide 231–2; suicide legislation morality see ethics and morality
situation in India 232–3; see also ethics mortality and disease: attribution in
and morality Eastern Europe to alcohol 170–1;
Law Commission of India, 232–3 stress as driver resulting in 90–4, 92–3;
Leenars, A. 224 see also suicide and suicidality
Lesbian, gay and bisexual (LGB) youth multi-system approaches: to mental
see youth, lesbian, gay and bisexual disorder therapy 17
Lester, D. 16, 178 Murphy, G. 23
Lineham, M. 15
literature: media effect on suicide narcissistic personality disorder:
behaviours 186–96, 188, 189 influence on suicide susceptibility
47–8
McAuliffe, N. 209 Navy personnel see personnel, military
McGirr, A. 71 Nemtsov, A. 177, 178
McGowan, P. 31 neutrophins: effect on suicidal behaviours
Major depressive disorder (MDD) 72 28–9
McKee, M. 98–9 Nielsen, D. 26
Mäkinen, I. 169–70, 178 Non-suicidal self injury (NSSI):
MacLeod, A. 15 significance of emotion dysregulation
Mann, J. 9, 24, 27, 56, 70 59–60
Maris, R. 7 Norström, T. 169, 174
Martikainen, P. 95
Marttunen, M. 46 O’Carroll, P. 6
Maser, J. 69 O’Connor, R. 11
Maslow, A. 227 O’Donnell, S. 215
Massachusetts Youth Risk Behavior old age: impact of fact of on suicide
Register 123 decisions 215–16; isolation of as
Massaldjieva, R. 71 significant for social crises 99–100
Mayo, D. 7 Oliver, R. 16
media: effect on suicide behaviours and online and offline representation: influence
rates 186–96, 188, 189; role in deciding of depictions on suicide behaviours
prominence of suicide clusters and 194–5
contagion 112–13 Ono, H. 28
Medically serious suicide attempters Oquendo, M. 71–2
(MSSAs) 72 Overholser, J. 44–5
 Index 241
pains, social and psychological: significance prisoners: situation of as significant for
for suicidal vulnerability 102–3; social crises 99–100
therapeutic action to alleviate 104 professionals, health: impact on preventing
Pandey, G. 29 LGB suicide 129–30
Paris, J. 46 protection, personal and social: impact
Parkash, V. 43 on LGB youth of family 128; impact
Patel, V. 3 on LGB youth of school-based 129–30;
Patton, J. 67 impact on LGB youth of health
peers, victimisation of: outcomes and professional 129–30; recommendations
correlation with self-harm and suicide to maximise among LGB youth 130–1
of LGB youth 126–7 psychology: as theory and explanation for
Perlis, R. 31 suicide 9–12
Perroud, N. 30, 43 Purcell, B. 99
Perry, L. 209
personality: ‘big three’ dimensions of and quick help interventions: characteristics as
suicidality tendency 41–2; five factor therapy for mental disorders 15
model of and suicidality tendency
40–1; see also behaviours, suicidal; Rackley, S. 207
personality disorders; see also aspects of Ramsey, P. 229
individual e.g. aggression; impulsivity; Ramstedt, M. 169
self-esteem; temperament, personal Rancaris, E. 176
personality disorders: influence on suicide Rassmussen, K. 45
susceptibility 45–9; see also particular Razvodovsky, Y. 172, 173, 175, 177
e.g. borderline personality disorder reality, representation: effect of media on
personnel, military: future direction for suicide behaviours 186–96, 188, 189
research on suicide of USA 162–3; region, of residence: impact on suicide
impact of combat exposure on suicide decisions 215–16
of USA 155–6; impact of culture on regions: variations in suicide rates in
suicide of in USA 156–8; interventions Hungary 140–1
to reduce suicide risk in USA 159–62; Reiss, N. 208
prevalence and incidence of suicides of relationship based approaches: to mental
USA 153–4; suicide risk factors among disorder therapy 15–16
USA 154–5 relationships, family: difficulties of
Peterson, L. 46 acceptance of LGB youth 127–8;
policies, government: implications for of essentiality of LGB need for support
alcohol abuse and suicide 181 from 128
politics and ideology: contributional role relationships, interpersonal: interruptions
in suicide in former USSR 94–5 of as driver for social crises 99–100
Pollock, L. 11 religion: impact on suicide decisions
Pompili, M. 44, 45, 47, 69 215–16
populations: at risk of social crises and reporting, media: effect on suicide
suicide 99–100 behaviours 186–96, 188, 189
Posttraumatic stress disorder (PSTD) 58–9 representation, media: effect on suicide
Poulter, M. 31 behaviours 186–96, 188, 189
prevalence and incidence: suicides, research: future direction of military
attempted suicide and suicidal suicide 162–3; media representation
behaviours 3, 39, 66, 82–90, 83, 86–7, effect on suicide behaviours 186–96,
88–9, 136, 138–9, 153–4 188, 189
prevention, suicide: need for strategies residence, location of: impact on suicide
enabling 13–14; see also particular decisions 215–16
strategies e.g. interventions, crisis; responses: to suicide clustering and
therapies contagion 116
Prichard, Z. 28 restriction, access: to means of suicide as
Pridemore, W. 172, 173, 180 therapy 17–18
242 Index
Rethelyi, J. 81 and suicide of LGB youth 126–7;
review, literature: of media effect on see also non-suicidal self injury
suicide behaviours 186–96, 188, 189 Seligman, M. 228
Reyes-Foster, B. 193 Sequeira, A. 31
Rihmer, A. 44 serotonin: role in suicide behaviours
risk: impact on suicide decisions 215–16 25–9
risk, forma: client suicidality features of services, community: suicide assessment
203–4: clinical diagnosis in relation to in mental health 208–9
204: definitions 202: etiology of suicidal Shea, S. 204
among LGB youth 124–6; of self-harm Shneidman, E. 5, 6–7, 102
205; of suicide risk, based on assessment Simko, V. 81
location 206; see also assessment, Simon, O. 69
suicidality Singh, R. 42
Risk Management Foundation of Sisask, M. 195
Harvard Medical Institution Snowden, A. 180
(RMFHMI) 203 societal approaches: to mental disorder
Robertson, L. 113 therapy 17–18
Rogers, C. 227 sociology: as theory and explanation for
Rossov, I. 174 suicide 12–13
Rousseau, J-J. 9 Soloff, P. 47
Rowell, K. 215 Spoden, F. 48
Roy, A. 23–4, 25, 30 standards and guidelines: need for vis a vis
Rujescu, D. 28 suicide ethics 225
rural areas: comparison with urban areas Statham, D. 25
for suicides in Hungary 140–1 Stickley, A. 173–4
Rurup, M. 99 Stone, M. 47–8
Rutz, W. 81 Storer, D. 15
Strelau, J. 43
Saiz, P. 27 stress, psycho-social: impact of gender on
Salkovskis, P. 15 in former USSR 87–90, 86–7, 88–9,
sanctions, cultural: significance for suicide 91–2, 92, 93–4; impact on health in
and suicidality 218 former USSR 90–4, 92–3; prevalence
Sarchiapone, M. 25 and patterns of in former USSR 82–90,
Sauliune, S. 180–81 83, 86–7, 88–9; significance as driver for
Scale for Suicide Ideation (SSI) 216 suicidal behaviours 100; significance at
school-based approaches: to mental micro, meso and macro-level in former
disorder therapy 16–17 USSR 80–1, 81; see also pains, social and
schools: impact on LGB youth of psychological; vulnerability, suicidal; see
protections of 129–30; also outcomes e.g. disease; suicide and
recommendations to maximise LGB suicidality
youth protection from suicide 131 Stuckler, D. 98–9
Schulsinger, F. 24 studies: impact of genetics on suicidal
screening, suicidality see assessment, behaviours 25–31
suicidality Suhrcke, M. 98–9
seasons: impact of variations in on suicides suicide and suicidality: ancient
in Hungary 141–2; impact on understandings of 3–4; and alcohol
distribution of suicides 137–40, 139 usage in Eastern Europe 171–6; ‘big
Segel, N. 25 three’ dimensions of personality and
Seifsafari, S. 215 tendency to 41–2; clinical diagnosis in
Seko, Y. 192 relation to risk of 204; clusters and
self-esteem: influence on suicide clustering of 110–16; conceptualisation
susceptibility 44–5 of 4–7; cultural theories and models
self-harm: assessment of risk factors for of 217–19; definition, context and
205; correlation with peer victimisation interpretations 224; definitions of 7–8,
 Index 243
66; distribution in space and time Tamas Z. 57
137–40, 139; etiology of risk among teachers: impact on LGB youth
LGB youth 124–6; features of client of protections of 129–30;
risk of 203–4; five factor model of recommendations to maximise
personality and tendency to 40–1; LGB youth protection from suicide
future direction for research on USA 131
military 162–3; geographical and temperament, personal: influence on
temporal variation in Hungary suicide susceptibility 42–4
140–2; impact and influence of media theories see models and theories
representations of 186–96, 188, 189; therapies: alleviating social exclusion and
impact of culture on 213–16; impact of psychological pain 103–4; characteristics
USA combat exposure on possibility of of mental disorder 14–18; features
155–6; impact of USA military culture of behavioural 14–15; features of
on possibility of 156–8; implications community based 16; features of multi-
for government policies 181; incidence, systemic 17; features of relationship
prevalence and patterns 3, 39, 66, 15–16; features of school based 16–17;
82–90, 83, 86–7, 88–9, 136, 138–9, features of societal 17–18; see also
153–4; influence and psychopathy of interventions, crisis; see also particular
aggression 71–3; influence and e.g. quick help interventions; restriction,
psychopathy of impulsivity 68–71; access
interventions to reduce risk of in USA Tischler, C. 208
military 159–62; likelihood and rates Tovilla-Zárate, C. 28
among LGB youth 124; need for treatments see therapies
standards and guidelines 225; protective tryptophan hydroxylase (TPH): influence
factors preventing 206; public health on suicidal behaviours 27
interventions to ease alcohol related Tsuang, M. 24
176–81; rates of in Eastern Europe Turecki, G. 27
169–70; risk factors for among USA twins: tudies of suicide patterns among
military 154–5; role of mental disorders 23–5
as cause of in Hungary 143–6;
significance of alcohol abuse as cause unemployment: impact on suicide rates
of 168–9; statistics of rates of 203; 98–9; see also outcomes e.g. exclusion,
theories explaining 8–13; see also social; isolation; stress, psychosocial;
assessment, suicidality; attempts, vulnerability, suicidal
suicide; behaviours, suicide; disease and United States of America: future direction
mortality; ideation, suicide; prevention, for research on suicide in military
suicide; vulnerability, suicidal; see also 162–3; impact of combat exposure on
considerations e.g. ethics and morality; suicide of military 155–6; impact of
law and legislation; see also drivers culture on suicide of military 156–8;
e.g. disorders, mental; stress, psycho- interventions to reduce suicide risk in
social; see also factors intensifying e.g. military 159–62; prevalence and
depression; relationships, family; incidence of suicides of military 153–4;
victimisation, peer; see also particular suicide risk factors among military
tendencies to e.g. personality disorders; 154–5
self-esteem; temperament, personal; urban areas: comparison with rural areas
see also situations impacting e.g. for suicides in Hungary 140–1
crises, socio-economic; relationships, Useda, J. 40
interpersonal
Suicide Ideation Scale (SIS) 216 Van Orden, K. 11
support, social: impact of existence of on Van Praag, H. 9
suicide decisions 215–16 Värnick, A. 172, 177
Sussex, J. 24 Värnik, A. 94
Swan, A. 68 Vella, M. 45
Symond, C. 71 Velting, D. 40
244 Index
Vermeiren, R. 72 Yen, S. 47
victimisation, peer: outcomes and Young, L. 44
correlation with self-harm and suicide of youth, lesbian, gay and bisexual: etiology
LGB youth 126–7 and prevalence of depression 126;
vulnerability, suicidal: characteristics 101; etiology of suicide risk among 124–6;
models of 105; see also situations impact of families, schools and health
influencing e.g. exclusion, social; pains, workers on suicide prevention 127–30;
social and psychological impact of peer victimisation on suicides
of 126–7; likelihood and rates of suicide
Wallenstein, S. 110 among 124; recommendations to
Wassarman, D. 27, 29, 30, 94, 172, 176 maximise protection from suicide
Weder, N. 28 130–31; suicide ideation rates and
Wender, P. 25 attempts among 123
Westerlund, M. 191, 192 Yukkala, T. 179
Wetzel, R. 23 Yumru, M. 43
Williams, J. 11 Yur’yev, A. 99–100
Willour, V. 31
Witte, T. 71 Zalsman, G. 28
Wojnar, M. 69 Zill, P. 26
Wong, P. 227 Zlotnick C. 57
World Health Organization 3, 7, 8, 98, Zouk, H. 69
170, 188, 215 Zupanc T. 180
Wyder, M. 70 Zweig-Frank, F. 46