Language, culture, gender, and intersectionalities in suicide theory, research, and prevention: Challenges and changes

Older adults make sense of their suicidal behavior: a Swedish interview study

Introduction

The aim of this study was to explore how individuals aged 70 or older living in Sweden understood a recent suicidal act, and what changed in them and around them in the aftermath.

Method

Four women and five men (age range 71-91 years) receiving care at a geriatric psychiatric outpatient clinic in a large Swedish city took part in two interviews about their most recent suicidal act. Most of the women and none of the men had engaged in prior suicidal acts. Interpretative phenomenological analysis was employed.

Results

The suicidal act was explained as a response to losses (in physical and cognitive functions, social roles and relationships) that rendered previous coping strategies unviable. The participants reported being dependent on a healthcare system that they experienced as indifferent and even dismissive of their suffering. The suicidal act was described as an unplanned act of despair. Positive changes followed for participants who reported having had suicidal ideation prior to the suicidal act and had insights into its triggers. Some gained access to needed medical care; others developed greater awareness of their psychological needs and became more effective at coping. Individuals who said that they had not had suicidal thoughts prior to the suicidal act and could not explain it reported no positive change in the aftermath. The respondents' narratives indicated gendered themes.

Discussion

Participants' age-related losses were in many cases exacerbated by negative interactions with health care providers, indicating that continued attention needs to be given to implicit ageism in medical professionals. The suicidal acts were described as impulsive, which was unexpected because a dominant belief is that older adult suicidal behavior is planned. One reason for the discrepancy may be that this study focused on nonfatal acts, and planned acts may be more likely to be fatal. Another reason could be shame due to suicide stigma. Alternatively, these acts were truly unplanned. The older adult suicide planning question should be addressed in larger studies across geographical and cultural settings. Future studies should also include questions about gender norms of suicidality and separately examine women's and men's data.

"I Will Die by My Own Hand": Understanding the Development of Suicide Capability in the Narratives of Individuals Who Have Attempted Suicide

Suicide capability is a multidimensional concept that facilitates the movement from suicidal ideation to suicide attempt. The three-step theory of suicide posits that three overarching contributors comprise suicide capability: acquired (fearlessness about death and high pain tolerance), dispositional (genetics), and practical (knowledge and access to lethal means) capability. Although extensive research has investigated relationships between individual contributors of capability and suicide attempts, little research has considered how an individual's capability for suicide develops as a combination of contributors. Given suicide is multifaceted and complex, our understanding of capability development is relatively limited. This potentially negatively impacts prevention and capacity reduction-focused intervention efficacy. Therefore, this study aimed to explore how suicide capability develops. Fourteen community-based suicide attempt survivors were recruited using convenience sampling. Individual narratives were collected using open-ended interviews, and data were analysed using narrative analysis. Results indicated that participant narratives contained two elements. The first included how capability development and suicide attempt facilitation were often underpinned by the relational interplay between acquired and practical contributors. For example, participants without a high pain tolerance seeking attempt methods that were perceived to be painless. The second element contained a novel finding relating to the agentic role of participants when deciding and attempting suicide. Agency was revealed within and across narratives emphasising the active role the individual plays in their movement from ideation-to-action. The role of individual agency in coming to a decision to take one's own life and then acting warrants further consideration within contemporary suicide theories.

Reevaluating the "deaths of despair" narrative: Racial/ethnic heterogeneity in the trend of psychological distress-related death

Despite the significant scientific advancement in deciphering the "deaths of despair" narrative, most relevant studies have focused on drug-, alcohol-, and suicide-related (DAS) deaths. This study directly investigated despair as a determinant of death and the temporal variation and racial heterogeneity among individuals. We used psychological distress (PD) as a proxy for despair and drew data from the US National Health Interview Survey-Linked Mortality Files 1997 to 2014, CDC (Centers for Disease Control and Prevention) Multiple Cause of Death database 1997 to 2014, CDC bridged-race population files 1997 to 2014, Current Population Survey 1997 to 1999, and the American Community Survey 2000 to 2014. We used Cox proportional hazards models to estimate mortality hazard ratios of PD and compared age-standardized PD- and DAS-related mortality rates by race/ethnicity and over time. We found that while Whites had a lower prevalence of PD than Blacks and Hispanics throughout the whole period, they underwent distinctive increases in PD-related death and have had a higher PD-related mortality rate than Blacks and Hispanics since the early 2000s. This was predominantly due to Whites' relatively high and increasing vulnerability to PD less the prevalence of PD. Furthermore, PD induced a more pervasive mortality consequence than DAS combined for Whites and Blacks. In addition, PD- and DAS-related deaths displayed a concordant trend among Whites but divergent patterns for Blacks and Hispanics. These findings suggest that 1) DAS-related deaths underestimated the mortality consequence of despair for Whites and Blacks but overestimated it for Hispanics; and 2) despair partially contributed to the DAS trend among Whites but probably not for Blacks and Hispanics.

Suicide Among Asian American, Native Hawaiian, and Pacific Islander Veterans: Rates and Methods, 2005-2019

INTRODUCTION

Knowledge of suicide rates and methods among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) Veterans remains sparse. Age- and sex-specific suicide rates, methods, and trends were examined among AANHPI Veterans and were compared with findings reported for all Veterans.

METHODS

For this population-based retrospective cohort study, average annual suicide rates (2005-2019) were computed in 2023 using population (U.S. Veterans Eligibility Trends and Statistics) and mortality (National Death Index [NDI]) data. The cohort included 416,454 AANHPI Veterans (356,146 males, 60,229 females) separated from military service and alive as of 1/1/2005. Suicide was determined from NDI underlying cause-of-death ICD-10 codes.

RESULTS

The age-adjusted average annual suicide rate among AANHPI Veterans increased 36.85% from 2005-2009 to 2015-2019 (2015-2019: 30.97/100,000). Relative to other ages, 2015-2019 suicide rates were highest among AANHPI Veterans 18-34 (overall: 53.52/100,000; males: 58.82/100,000; females: 32.24/100,000) and exceeded those of similarly aged Veterans in the overall Veteran population (overall: 44.71/100,000; males: 50.59/100,000; females: 19.24/100,000). The sex difference in suicide rates was lower among AANHPI Veterans than in Veterans overall (relative risk [males to females]=1.65 and 2.33, among those 18-54). Firearms were used less and suffocation more among AANHPI Veterans, relative to Veterans overall.

CONCLUSIONS

Suicide among AANHPI Veterans is an increasing public health concern, with younger males and females at particularly elevated risk. Lethal means safety strategies for AANHPI Veterans should consider distinctions in suicide methods compared to the overall Veteran population. Research is warranted to understand the lower magnitude sex difference in suicide rates among AANHPI Veterans.

"I Can't See an End in Sight." How the COVID-19 Pandemic May Influence Suicide Risk

Background: The COVID-19 pandemic and its consequences may affect population mental health and suicide risk. Aims: To explore the experiences among suicidal individuals who made calls to a suicide prevention hotline and to identify factors and psychological responses that may influence suicide risk. Method: We identified 60 eligible recorded calls to Taiwan's suicide prevention hotline (January 23, 2020-May 31, 2020) and analyzed the transcripts using a framework analysis. Results: We identified three themes: (a) effects of the COVID-19 pandemic on society (impacts on local economies, the fear of contagion, and disruptions caused by outbreak control measures); (b) stress experienced by callers, including increased challenges (financial burden, restricted freedom of movement, interpersonal conflicts, feelings of uncertainty, and education/career interruption) and reduced support (reduced access to health services and social support); and (c) the callers' psychological responses to stress, including anxiety, sleep disturbance, depression, loneliness, hopelessness, and entrapment, which may increase suicide risk. Limitations: Only the experiences among those who sought help by calling the hotline during the early months of the pandemic in 2020 were explored. Conclusion: Our findings revealed the potential process underlying the impact of the COVID-19 pandemic on suicide risk and have implications for prevention and intervention strategies.

Suicide Scripts in Italian Newspapers

Background: There is substantial variability, by culture, in suicide rates, and also in suicide beliefs and attitudes. Suicide beliefs and attitudes predict actual suicidality. They also are elements of cultural scripts of suicide. Most suicide-scripts research has been conducted in Anglophone countries. Aims: This study investigates women's and men's suicide scripts in Italy. Methods: Italy's suicide scripts, including beliefs about what causes suicide, were explored via analyses of newspaper stories (N = 923) of women's and men's suicides. Results: Italian newspapers mostly featured men's suicide stories, consistent with Italian men's higher suicide mortality. Women's suicide was narrated as an unexpected act signaling personal (e.g., emotional and private-relationship) problems. By contrast, men's suicide was framed as relatively understandable response to serious public-life/social adversities (e.g., an economic downturn), and as a death of legitimate despair. Limitations: Social media suicide stories were not included in this study. Conclusion: In Italy, as in several countries with higher male suicide mortality, female suicide is psychologized and considered irrational while male suicide is viewed as a symptom of serious public-life/social problems, and therefore as deserving respect and empathy. The preference for social explanations of male suicide, together with the empathic attitudes, may contribute to male suicide being relatively more permissible and less stigmatized, and therefore also to men's higher suicide mortality.

Studying Scripts of Women, Men and Suicide: Qualitative-Method Development and Findings from Nepal

Information about suicidal behavior in Nepal is limited. According to official records, suicide rates were high until the year 2000 and declined thereafter. Official records are considered unreliable and a gross undercounting of suicide cases, particularly female cases. Suicide research in Nepal has been mostly epidemiologic and hospital-based. Little is known about how suicide is understood by Nepali people in general-including dominant suicide attitudes and beliefs in Nepal. Suicide attitudes and beliefs, which are elements of a culture's suicide scripts, predict actual suicidality. Drawing on suicide-script theory, we developed and used a semi-structured survey to explore Nepali beliefs about female and male suicide. The informants were adult (Mage = 28.4) university students (59% male). Female suicide was believed to be a response to the society-sanctioned oppression and abuse that women are subjected to, in their family and community. The prevention of female suicide was viewed as requiring dismantling ideologies, institutions, and customs (e.g., child marriage, dowry) that are oppressive to women, and ensuring that women are protected from violence and have equal social and economic rights and opportunities. Male suicide was believed to be a symptom of societal problems (e.g., unemployment) and of men's psychological problems (e.g., their difficulties in managing emotions). The prevention of male suicide was viewed as requiring both societal (e.g., employment opportunities) and individual remedies (e.g., psychological counseling). This study's findings suggest that a semi-structured survey can be a fruitful method to access the suicide scripts of cultures about which there is limited research.

Affiliation to a Social Group as a Preventive Factor in Suicidal Behaviors in Children and Adolescents during the COVID-19 Pandemic

Suicide is one of the most common causes of death in the population of children and adolescents. Available data show the continuous growth of this phenomenon and the ineffectiveness of prevention programs. Additionally, the COVID-19 pandemic significantly affected young people's mental health, including an increased risk of suicidal behaviors due to limited direct contact with the school and peer groups in favor of the home environment. Therefore, the aim of this narrative review was to consider the risk factors and protective factors for suicidal behavior in the under-18 population, with a particular focus on the importance of belonging to a social group and building identification with it as a phenomenon protecting against suicidal behavior. Additionally, in this review, we evaluate how the COVID-19 pandemic affected these relationships. The PubMed database was used in the search with the following keywords: suicide, suicide behaviors, child and adolescent suicide behaviors, group affiliation, family affiliation, ethnicity, religious affiliation, and the COVID-19 pandemic, with articles published between 2002 and 2022 analyzed. Research conducted to date indicates that both sustained and stable family and peer relationships, as well as a sense of identification and belonging, noticeably reduce the risk of suicidal behavior. Ethnic or cultural affiliation seems to have been particularly important during the isolation in the home environment caused by the COVID-19 pandemic. Additionally, it has been shown that while in lockdown, contact through social media with individuals' identification groups was associated with a reduced chance of emotional crises. Furthermore, regardless of cultural background, attachment to a particular group correlates with enhanced psychiatric state of children and adolescents. Thus, available data highlight the need for building and maintaining affiliations with suitable groups as a protective factor against suicidal behaviors.

Two sides of the same coin? The association between suicide stigma and suicide normalisation

AIMS

Evidence suggests that suicide stigma (i.e. negative attitudes towards persons affected by suicide/suicidality) and suicide normalisation (i.e. liberal attitudes towards suicide) are both associated with increased suicide risk. Despite conceptual similarities and potential interaction, suicide stigma and suicide normalisation have usually been investigated separately. We used cross-sectional data from a community sample to test the association between suicide stigma and suicide normalisation as well as to identify their respective determinants and consequences.

METHODS

Participants were N = 3.269 adults recruited from an established online-panel using quotas to reflect the composition of the German general population with regard to age, gender, education and region. We collected information about suicide stigma, suicide normalisation, intentions to seek help for suicidality, current suicidality, suicide literacy, negative mood and socio-demographic variables. We used regression modelling to determine the association between suicide stigma and suicide normalisation as well as to identify their determinants and consequences.

RESULTS

Suicide stigma and suicide normalisation were inversely associated so that higher suicide stigma scores were linked to lower suicide normalisation. More suicide stigma was associated with reduced intentions to seeking professional help, increased willingness to seek help from family and friends and lower odds to experience current suicidality, however the association between suicide stigma and intentions to seek professional help diminished after controlling for confounding variables. Increased suicide normalisation was linked to reduced intentions to seek help from professionals or family and friends, as well as higher odds to experience current suicidality, even after controlling for confounding variables.

CONCLUSIONS

Our findings suggest that interventions to reduce public suicide stigma are at risk to unintentionally increase suicide normalisation, which appears to be a key barrier to seeking help for suicidality. Future research should therefore identify strategies to improve attitudes towards persons affected by suicidality that avoid normalisation, i.e. do not convey the message of suicide as an acceptable solution for difficult life situations. One strategy with great potential to safely reduce public suicide sigma could be interventions that stimulate interpersonal contact with affected persons sharing their recovery story.

Is Lethality Different between Males and Females? Clinical and Gender Differences in Inpatient Suicide Attempters

According to the gender paradox in suicidology, an important sex difference has been reported with a preponderance of females in nonfatal suicidal behavior and a preponderance of males in completed suicide. Furthermore, females and males present different risk factors for suicide. The present study explored possible clinical differences between male and female psychiatric inpatients who had recently attempted suicide. The study included 177 adult inpatients hospitalized following a suicide attempt at the University Psychiatric Clinic, Sant'Andrea Hospital, Sapienza University of Rome. Clinical features assessed included psychiatric diagnosis, method and lethality of suicide attempts using the Risk/Rescue Rating Scale, the history of suicide attempts, age at onset of psychiatric illness, the presence of substance or alcohol use, and the length of stay. The results found that males and females differed in the method used for the suicide attempt, the scores for risk and rescue, and the length of hospitalization post-suicide attempt. In conclusion, identifying gender characteristics of patients at higher risk of suicide is important for implementing specific suicide prevention strategies and reducing the risk of future suicidal behavior in psychiatric inpatients.

Job loss, financial strain, and housing problems as suicide precipitants: Associations with other life stressors

Previous research has shown that job loss, financial strain, and/or loss of housing (JFH) in midlife elevate suicide risk. In this study based on the 2017–2019 National Violent Death Reporting System, we examined other suicide precipitants and contributors of decedents whose suicide was in part precipitated by JFH and the circumstances under which they died. First, we examined all adult decedents (N = 94,454; 74,042 males [78.4%] and 20,412 females [21.6%]) and then focused on decedents age 45–64 (N = 34,208; 25,640 males [75%] and 8568 females [25.0%]). The 45–64 age group had the highest rate of JFH (22.0% for males and 15.1% for females) as a suicide precipitant. The results of generalized linear models for all adult suicide decedents of both sexes showed that the 45–64 age group (IRR = 2.02, 95% CI = 1.89–2.16), compared to 65+ age group, and relationship problems, mental disorders, and alcohol problems were associated with significantly higher risk of JFH-precipitated suicide. In male decedents age 45–64, JFH was positively associated with depressed mood (IRR = 1.95, 95% CI = 1.85–2.06), alcohol problems (IRR = 1.14, 95% CI = 1.07–1.21), and number of crises (IRR = 1.48, 95% CI = 1.43–1.53). In female decedents age 45–64, JFH was positively associated with relationship problems (IRR = 1.19, 95% CI = 1.05–1.35), legal problems (IRR = 1.27, 95% CI = 1.06–1.54), depressed mood (IRR = 1.78, 95% CI = 1.59–1.99), and number of crises (IRR = 1.58, 95% CI = 1.48–1.68). In both sexes, the risk of JFH was also positively associated with a college education. In female decedents, JFH risk was higher among divorced or never-married individuals. Coroner/medical examiner and law enforcement agency reports show that some experienced depression and started misusing alcohol and/or other substances following a job loss, but others had these problems throughout life, which caused/contributed to JFH. These findings show the significance of suicide prevention approaches at both systemic (generous unemployment insurance, housing subsidies) and individual (treatment of depression and alcohol/substance misuse problems and social support/connection) levels.

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16.2% of male and 13.0% of female suicide decedents age 18+ in 2017–2019 had job/finance/housing problems (JFH).

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Among decedents age 45–64, 22.0% of male and 15.1% of female had JFH.

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JFH was positively associated with number of crises, depressed mood, and relationship and alcohol problems in both sexes.

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Suicide prevention approaches are needed at both systemic and individual levels.

Women's Suicide in the First-Year Postpartum: A Population-based Study

BACKGROUND

In dominant suicidology there is a long traditionof theorizing that women are protected from suicide, particularly when mothers and during the postpartum. Studies have mostly confirmed the postpartum suicide-protection theory, with low suicide mortality generally observed among postpartum women. A limitation of these studies is that most were conducted in majority European-descent-population countries. A challenge to the more general maternal suicide-protection theory is that in East-Asia women of childbearing age exhibit substantial suicidality, nonfatal and fatal. This study evaluated whether suicide is less likely in first-year postpartum women as compared to women past the first-year postpartum.

METHODS

This population-based, nested case-control study focused on women whose live birth was between 2001 and 2016 in East-Asian Taiwan. To ascertain suicide outcomes, the women were followed until 2017. For each suicide case, four control cases were randomly selected from the Birth Certificate Application dataset, with a 1:4 matching ratio based on age of last live-delivery and parity (one delivery record vs. two or more records) (cases N = 1571; controls N = 6284). Conditional logistic regression analyses were conducted to assess whether suicide was less likely in women in the first-year postpartum relative to women past the first-year postpartum.

RESULTS

The odds ratios of suicide were elevated at 42 days postpartum [Odds Ratio (OR) = 2.06; 95% Confidence Interval (CI) = (1.04, 4.16)], six-months postpartum [OR = 2.28; 95% CI = (1.60, 3.29)] and one-year postpartum [OR = 2.26; 95% CI = (1.76, 2.96)], when controlling for sociodemographic and mental-disorder variables. Suicide was more likely in women who were single at index birth, had lower socioeconomic status, or had a mental disorder history.

CONCLUSION

Our findings suggest that the postpartum stage is not suicide-protective per se. Whether the postpartum stage is associated with suicide protection or suiciderisk appears to depend on context and culture.