Effect of 11 September 2001 on suicide and homicide in England and Wales

The Anomalous Effect of COVID-19 Pandemic Restrictions on the Duration of Untreated Psychosis (DUP)

We investigated the impact of COVID-19 restrictions on the duration of untreated psychosis (DUP). First-episode psychosis admissions (n=101) to STEP Clinic in Connecticut showed DUP reduction (p=.0015) in the pandemic, with the median reducing from 208 days during the pre-pandemic to 56 days in the early pandemic period and subsequently increasing to 154 days (p=.0281). Time from psychosis onset to anti-psychotic prescription decreased significantly in the pandemic (p=.0183), with the median falling from 117 to 35 days. This cohort study demonstrates an association between greater pandemic restrictions and marked DUP reduction and provides insights for future early detection efforts.

Suicide in Flanders, Belgium, after terrorist attacks

Little is known about the association between terrorism and suicide. This study investigates suicide numbers in Flanders, Belgium before and after the Paris-attacks (13/11/2015) and Brussels-attacks (22/03/2016). Population mortality data for suicide were gathered from the Agency for healthcare. Suicides in Flanders, Belgium, were higher after both attacks. The increase was higher after the Paris-attacks, compared to the attacks in Brussels, Belgium. The effect of a close-by, but still foreign attack (the Paris-attacks in France) on suicide numbers is larger than that of an attack inside the country (the Brussels-attacks), possibly due to a difference in threat experience and coping possibilities.

State-Level Data on Suicide Mortality During COVID-19 Quarantine: Early Evidence of a Disproportionate Impact on Racial Minorities

The unprecedented impact of COVID-19 has raised concern for the potential of increased suicides due to a convergence of suicide risk factors. We obtained suicide mortality data to assess completed suicides during the period of strict stay-at-home quarantine measures in Connecticut and compared this data with previous years. While the total age-adjusted suicide mortality rate decreased by 13% during the lockdown period compared with the 5-year average, a significantly higher proportion of suicide decedents were from racial minority groups. This finding may provide early evidence of a disproportionate impact from the social and economic challenges of COVID-19 on minority populations.

Comparison of impulsivity, aggression and suicidality between prisoners in Nigeria who have committed homicide and those who have not

Most studies of prisoners, the nature of their offending and any related characteristics have been conducted in rich Western countries. In Nigeria, prison conditions differ in many important respects, key among them that prisoners share large communal spaces much of the time-up to 50 men sleeping in the same space as well as spending the day together. Our aim was to compare levels of impulsivity, aggression and suicide-related behaviours between prisoners in one prison in Nigeria who had committed a homicide and those who had not, allowing for socio-demographic factors. A case-control study design was employed with 102 homicide and an equal number of non-homicide offenders. Each participant was interviewed using the Abbreviated Barratt Impulsiveness Scale for impulsivity, the Modified Overt Aggression Scale for aggression, the MINI International Neuropsychiatric Interview (Module C) for suicide-related behaviours, and a questionnaire for ascertaining socio-demographic characteristics. On bivariate analysis, motor impulsivity was higher among homicide offenders (p = .014) while non-planning was higher among non-homicide offenders (p = .006), but this relationship was affected by demographic variables. Physical aggression levels did not distinguish the two groups, but homicide offenders were less likely to record property-directed and auto-aggressive behaviours (p < .05). By contrast, on average, scores for suicide-related behaviours were lower among the homicide offenders (p = .001), with non-homicide offenders showing a mean score in the high-risk category (13.25; SD, 1.25). As motor impulsivity significantly differentiated the groups, this may be an important measure to add to any risk assessment battery when there are concerns about homicidal behaviours. In this sample, history of interpersonal aggression did not distinguish the groups. People with indications of self-harm or suicide-related behaviours may be at less risk of violence to others, but care should be taken in interpreting this finding as it is not entirely consistent with other findings.

Can we expect an increased suicide rate due to Covid-19?

Human disasters come in all shapes and sizes including wars, terrorist violence, natural events, economic recessions and depressions as well as infection. As a species more fragile than we often allow, humans would be expected to adversely react to these types of disasters in terms of mental ill health and possibly suicidal behaviour leading to increased demands on the Mental Health services. This narrative historical paper examines relevant studies into how previous disasters affected mental health and suicidal behaviour. The characteristics of what is known of the current Covid-19 disease are analysed and compared to other types of disasters with a view to gaining some insight into what we might expect. Of all the types of disasters, economic recession appears most toxic. Mitigating the worst effects of recession appears to be protective. Particularly vulnerable groups are identified in whom we might expect an increase in suicidal behaviour.

Genetic and environmental pathways to suicidal behavior: Reflections of a genetic epidemiologist

This paper presents a tentative typology of genetic and environmental pathways to suicidal behavior. Ten pathways are proposed and briefly illustrated: (i) direct effects from psychiatric disorders; (ii) direct effects from personality; (iii) direct effects of early adversity; (iv) direct effects of current adversity; (v) indirect effects of genes on selection into adversity (gene–environment correlation); (vi) interactions between genetic risk and current adversity: gene–environment interaction; (vii) interactions between early and current adversity: environment–environment interaction; (viii) interactions between culture and genes; (ix) dynamic developmental pathways involving causal loops from genes to environment and back again; and (x) gene × environment × development interaction.

Aircraft-Assisted Pilot Suicides in the General Aviation Increased for One-Year Period after 11 September 2001 Attack in the United States

Pilot aircraft-assisted suicides (AAS) are rare, and there is limited understanding of copycat phenomenon among aviators. The aim of this study was to evaluate the possible effect the 11 September 2001, terrorist attacks had on pilot AASs in the U.S. Fatal aviation accidents in the National Transportation Safety Board (NTSB) database were searched using the following search words: “suicide”, “murder-suicide” and “homicide-suicide”. The timeline between 11 September 1996, and 11 September 2004, was analyzed. Only those accidents in which NTSB judged that the cause of the accident was suicide were included in the final analysis. The relative risk (RR) of the pilot AASs in all fatal accidents in the U.S. was calculated in order to compare the one, two, and three-year periods after the September 11 terrorist attacks with five years preceding the event. The RR of a fatal general aviation aircraft accident being due to pilot suicide was 3.68-fold (95% confidence interval 1.04–12.98) during the first year after 11 September 2001, but there was not a statistically significant increase in the later years. This study showed an association, albeit not determinate causal effect, of a very specific series of simultaneous terrorist murder-suicides with subsequent pilot AASs.

Suicidality Risk and (Repeat) Disaster Exposure: Findings From a Nationally Representative Population Survey

OBJECTIVE

Despite growing awareness of adverse mental health consequences, the scarce existing evidence on the link of disaster exposure and suicidality has remained inconclusive, and the differential suicidality risk associated with distinct levels of natural and man-made disaster exposure is unknown. We therefore investigated the lifetime prevalence and risk of suicidal behavior associated with natural and man-made disaster exposure in Australia.

METHOD

We utilized data from a nationally representative mental health survey (n = 8,841). Univariate and multivariate logistic regression analyses examined the lifetime risk of suicidal thoughts, plans, and attempts associated with varied types and levels of disaster exposure. We focused explicitly on natural and man-made disasters while controlling for other types of trauma exposure, including established risk factors for suicidality.

RESULTS

Multivariate analyses indicated that those exposed to multiple natural (adjusted odds ratio [AOR] = 2.21, 95% confidence interval [CI] = [1.04, 4.71], p < .05) or man-made disasters (AOR 3.4, 95% CI = [1.20, 9.58] p < .05) were at significantly greater risk of making suicide attempts, whereas single natural or man-made disaster exposure was not associated with an increased risk of suicidal behavior.

CONCLUSIONS

Our study findings establish the differential suicidality risk associated with natural and man-made disaster exposure in Australia and highlight the critical role of repeat disaster exposure across distinct disaster types. Suicidal behavior may warrant increasing attention in psychosocial recovery schemes, particularly in the context of disaster-prone areas and for population groups at elevated risk of repeat disaster exposure.

Longitudinal Patterns and Predictors of Depression Trajectories Related to the 2014 Occupy Central/Umbrella Movement in Hong Kong

OBJECTIVES

To examine the longitudinal patterns and predictors of depression trajectories before, during, and after Hong Kong's 2014 Occupy Central/Umbrella Movement.

METHODS

In a prospective study, between March 2009 and November 2015, we interviewed 1170 adults randomly sampled from the population-representative FAMILY Cohort. We used the Patient Health Questionnaire-9 to assess depressive symptoms and probable major depression. We investigated pre-event and time-varying predictors of depressive symptoms.

RESULTS

We identified 4 trajectories: resistant (22.6% of sample), resilient (37.0%), mild depressive symptoms (32.5%), and persistent moderate depression (8.0%). Baseline predictors that appeared to protect against persistent moderate depression included higher household income (odds ratio [OR] = 0.18; 95% confidence interval [CI] = 0.06, 0.56), greater psychological resilience (OR = 0.63; 95% CI = 0.48, 0.82), more family harmony (OR = 0.68; 95% CI = 0.56, 0.83), higher family support (OR = 0.80; 95% CI = 0.69, 0.92), better self-rated health (OR = 0.28; 95% CI = 0.16, 0.49), and fewer depressive symptoms (OR = 0.59; 95% CI = 0.43, 0.81).

CONCLUSIONS

Depression trajectories after a major protest are comparable to those after major population events. Health care professionals should be aware of the mental health consequences during and after social movements, particularly among individuals lacking social support.

The Terror Attacks of 9/11 and Suicides in Germany: A Time Series Analysis

Data on the effect of the September 11, 2001 (9/11) terror attacks on suicide rates remain inconclusive. Reportedly, even people located far from the attack site have considerable potential for personalizing the events that occurred on 9/11. Durkheim's theory states that suicides decrease during wartime; thus, a decline in suicides might have been expected after 9/11. We conducted a time series analysis of 164,136 officially recorded suicides in Germany between 1995 and 2009 using the algorithm introduced by Box and Jenkins. Compared with the average death rate, we observed no relevant change in the suicide rate of either sex after 9/11. Our estimates of an excess of suicides approached the null effect value on and within a 7-day period after 9/11, which also held when subsamples of deaths in urban or rural settings were examined. No evidence of Durkheim's theory attributable to the 9/11attacks was found in this sample.

Understanding Bhutanese refugee suicide through the interpersonal-psychological theory of suicidal behavior

Attention has been drawn to high rates of suicide among refugees after resettlement and in particular among the Bhutanese refugees. This study sought to understand the apparent high rates of suicide among resettled Bhutanese refugees in the context of the Interpersonal-Psychological Theory of Suicidal Behavior (IPTS). Expanding on a larger investigation of suicide in a randomly selected sample of Bhutanese men and women resettled in Arizona, Georgia, New York, and Texas (Ao et al., 2012), the current study focused on 2 factors, thwarted belongingness and perceived burdensomeness, examined individual and postmigration variables associated with these factors, and explored how they differed by gender. Overall, factors such as poor health were associated with perceived burdensomeness and thwarted belongingness. For men, stressors related to employment and providing for their families were related to feeling burdensome and/or alienated from family and friends, whereas for women, stressors such as illiteracy, family conflict, and being separated from family members were more associated. IPTS holds promise in understanding suicide in the resettled Bhutanese community.

Ethical Considerations in Emergency Planning, Preparedness, and Response to Acts of Terrorism

Throughout the globe, healthcare providers are increasingly challenged with the specter of terrorism and the fallout from weapons of mass destruction. Preparing for and responding to such manmade emergencies, however, threatens the ethical underpinnings of routine, individualized, patient-centered, emergency healthcare. The exigency of a critical incident can instantly transform resource rich environs, to those of austerity. Healthcare workers, who only moments earlier may have been seeing two to three patients per hour, are instantly thrust into a sea of casualties and more basic lifeboat issues of quarantine, system overload and the thornier determinations of who will be given every chance to live and who will be allowed to die. Beyond the tribulations of triage, surge capacity, and the allocation of scarce resources, terrorism creates a parallel need for a host of virtues not commonly required in daily medical practice, including prudence, courage, justice, stewardship, vigilance, resilience, and charity. As a polyvalent counterpoint to the vices of apathy, cowardice, profligacy, recklessness, inflexibility, and narcissism, the virtues empower providers at all levels to vertically integrate principles of safety, public health, utility, and medical ethics at the micro, meso, and macro levels. Over time, virtuous behavior can be modeled, mentored, practiced, and institutionalized to become one of our more useful vaccines against the threat of terrorism in the new millennium.

The dappled nature of causes of psychiatric illness: replacing the organic-functional/hardware-software dichotomy with empirically based pluralism

Our tendency to see the world of psychiatric illness in dichotomous and opposing terms has three major sources: the philosophy of Descartes, the state of neuropathology in late nineteenth century Europe (when disorders were divided into those with and without demonstrable pathology and labeled, respectively, organic and functional), and the influential concept of computer functionalism wherein the computer is viewed as a model for the human mind-brain system (brain=hardware, mind=software). These mutually re-enforcing dichotomies, which have had a pernicious influence on our field, make a clear prediction about how 'difference-makers' (aka causal risk factors) for psychiatric disorders should be distributed in nature. In particular, are psychiatric disorders like our laptops, which when they dysfunction, can be cleanly divided into those with software versus hardware problems? I propose 11 categories of difference-makers for psychiatric illness from molecular genetics through culture and review their distribution in schizophrenia, major depression and alcohol dependence. In no case do these distributions resemble that predicted by the organic-functional/hardware-software dichotomy. Instead, the causes of psychiatric illness are dappled, distributed widely across multiple categories. We should abandon Cartesian and computer-functionalism-based dichotomies as scientifically inadequate and an impediment to our ability to integrate the diverse information about psychiatric illness our research has produced. Empirically based pluralism provides a rigorous but dappled view of the etiology of psychiatric illness. Critically, it is based not on how we wish the world to be but how the difference-makers for psychiatric illness are in fact distributed.

Short-term and medium-term health effects of 9/11

The New York City terrorist attacks on Sept 11, 2001 (9/11), killed nearly 2800 people and thousands more had subsequent health problems. In this Review of health effects in the short and medium terms, strong evidence is provided for associations between experiencing or witnessing events related to 9/11 and post-traumatic stress disorder and respiratory illness, with a correlation between prolonged, intense exposure and increased overall illness and disability. Rescue and recovery workers, especially those who arrived early at the World Trade Center site or worked for longer periods, were more likely to develop respiratory illness than were other exposed groups. Risk factors for post-traumatic stress disorder included proximity to the site on 9/11, living or working in lower Manhattan, rescue or recovery work at the World Trade Center site, event-related loss of spouse, and low social support. Investigators note associations between 9/11 exposures and additional disorders, such as depression and substance use; however, for some health problems association with exposures related to 9/11 is unclear.

Effect of 11 September 2001 terrorist attacks in the USA on suicide in areas surrounding the crash sites

BACKGROUND

The terrorist attacks in the USA on 11 September 2001 affected suicide rates in two European countries, whereas overall US rates remained stable. The effect on attack site rates, however, has not been studied.

AIMS

To examine post-attack suicide rates in areas surrounding the three airline crash sites.

METHOD

Daily mortality rates were modelled using time series techniques. Where rate change was significant, both duration and geographic scope were analysed.

RESULTS

Around the World Trade Center, post-attack 180-day rates dropped significantly (t = 2.4, P = 0.0046), whereas comparison condition rates remained stable. No change was observed for Pentagon or Flight 93 crash sites.

CONCLUSIONS

The differential effect by site suggests that proximity may be less important that other event characteristics. Both temporal and geographic aspects of rate fluctuation after sentinel events appear measurable and further analyses may contribute valuable knowledge about how sociological forces affect these rates.

The interpersonal theory of suicide

Suicidal behavior is a major problem worldwide and, at the same time, has received relatively little empirical attention. This relative lack of empirical attention may be due in part to a relative absence of theory development regarding suicidal behavior. The current article presents the interpersonal theory of suicidal behavior. We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs-thwarted belongingness and perceived burdensomeness (and hopelessness about these states)-and further that the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior. According to the theory, the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences. In the current article, the theory's hypotheses are more precisely delineated than in previous presentations (Joiner, 2005), with the aim of inviting scientific inquiry and potential falsification of the theory's hypotheses.

The influence of a major disaster on suicide risk in the population

The authors investigated the relationship between the September 11, 2001 terrorist attacks and suicide risk in New York City from 1990 to 2006. The average monthly suicide rate over the study period was 0.56 per 100,000 people. The monthly rate after September 2001 was 0.11 per 100,000 people lower as compared to the rate in the period before. However, the rate of change in suicide was not significantly different before and after the disaster, and regression discontinuity analysis indicated no change at this date. There was no net change in the suicide rate in New York City attributable to this disaster, suggesting that factors other than exposure to traumatic events (e.g., cultural norms, availability of lethal methods) may be key drivers of suicide risk in this context.

No evidence of suicide increase following terrorist attacks in the United States: an interrupted time-series analysis of September 11 and Oklahoma City

There is substantial evidence of detrimental psychological sequelae following disasters, including terrorist attacks. The effect of these events on extreme responses such as suicide, however, is unclear. We tested competing hypotheses about such effects by employing autoregressive integrated moving average techniques to model the impact of September 11 and the Oklahoma City bombing on monthly suicide counts at the local, state, and national level. Unlike prior studies that provided conflicting evidence, rigorous time series techniques revealed no support for an increase or decrease in suicides following these events. We conclude that while terrorist attacks produce subsequent psychological morbidity and may affect self and collective efficacy well beyond their immediate impact, these effects are not strong enough to influence levels of suicide mortality.

Suicide in paradise: aftermath of the Bali bombings

BACKGROUND

The relationship between the Bali (Indonesia) bombings of October 2002 and suicide has not previously been investigated, despite anecdotal evidence of the economic and psychological consequences of these attacks.

METHOD

Suicide rates were calculated over the period 1994-2006 in three Bali regencies to determine whether suicide increased in the period following the first Bali bombings. Poisson regression and time-series models were used to assess the change in suicide rates by sex, age and area in the periods before and after October 2002.

RESULTS

Suicide rates (age-adjusted) increased in males from an average of 2.84 (per 100 000) in the period pre-2002 to 8.10 in the period post-2002, and for females from 1.51 to 3.68. The greatest increases in suicide in the post-2002 period were in the age groups 20-29 and 60 years, for both males and females. Tourist arrivals fell significantly after the bombings, and addition of tourism to models reduced relative risk estimates of suicide, suggesting that some of the increase may be attributable to the socio-economic effects of declines in tourism.

CONCLUSIONS

There was an almost fourfold increase in male suicide risk and a threefold increase in female suicide risk in the period following the 2002 bombings in Bali. Trends in tourism did not account for most of the observed increases. Other factors such as indirect socio-economic effects and Balinese notions of collective guilt and anxieties relating to ritual neglect are important in understanding the rise in suicide in the post-2002 period.

Interventionist causal models in psychiatry: repositioning the mind-body problem

The diversity of research methods applied to psychiatric disorders results in a confusing plethora of causal claims. To help make sense of these claims, the interventionist model (IM) of causality has several attractive features. First, it connects causation with the practical interests of psychiatry, defining causation in terms of 'what would happen under interventions', a question of key interest to those of us whose interest is ultimately in intervening to prevent and treat illness. Second, it distinguishes between predictive-correlative and true causal relationships, an essential issue cutting across many areas in psychiatric research. Third, the IM is non-reductive and agnostic to issues of mind-body problem. Fourth, the IM model cleanly separates issues of causation from questions about the underlying mechanism. Clarifying causal influences can usefully structure the search for underlying mechanisms. Fifth, it provides a sorely needed conceptual rigor to multi-level modeling, thereby avoiding a return to uncritical holistic approaches that 'everything is relevant' to psychiatric illness. Sixth, the IM provides a clear way to judge both the generality and depth of explanations. In conclusion, the IM can provide a single, clear empirical framework for the evaluation of all causal claims of relevance to psychiatry and presents psychiatry with a method of avoiding the sterile metaphysical arguments about mind and brain which have preoccupied our field but yielded little of practical benefit.

Effect of 7 July 2005 terrorist attacks in London on suicide in England and Wales

BACKGROUND

A reduction in suicide in England and Wales has been reported after the attacks of 11 September 2001 in the USA. It may be plausible therefore to expect a much greater impact on suicide in the UK in response to the events of 7 July 2005, caused by the first suicide terrorist attack by Islamic extremists on British soil.

AIMS

To examine the effect of the 7 July 2005 terrorist attacks in London on suicide rates in England and Wales.

METHOD

Analysis of number of suicide (ICD-10 codes X60-X84) and undetermined injury deaths (ICD-10 codes Y10-Y34) reported in England and Wales in the 12 weeks before and after 7 July 2005. We used Shewhart Control Charts based on Poisson rates to explore adjusted daily and weekly suicide rates and rate differences with respect to 7 July 2005.

RESULTS

A brief but significant reduction in daily suicide rate was observed a few days after the terrorist attack in London on 7 July 2005. Further reduction was also observed on the 21 July 2005, coinciding with the second wave of attacks. No similar reduction in suicide was seen during the same period in the previous 4 years. Poisson regression models with indicator variables for each day in July 2005 revealed a reduction of 40% of the expected daily rate for these 2 days only. We found no evidence of any longer-term effect on suicide.

CONCLUSIONS

The study findings are contrary to our expectation and only weakly support Durkheim's theory that periods of national threat lower the suicide rate through the impact on social cohesion. It is possible that previous experience of IRA terrorism in the UK may have limited the effect of the 7 July 2005 attacks on suicide in England and Wales. The shock value of suicide terrorism and its psychological potency appear to diminish over time as the tactic becomes overused.

Sampling and design challenges in studying the mental health consequences of disasters

Disasters are unpredictable and frequently lead to chaotic post-disaster situations, creating numerous methodologic challenges for the study of the mental health consequences of disasters. In this commentary, we expand on some of the issues addressed by Kessler and colleagues, largely focusing on the particular challenges of (a) defining, finding, and sampling populations of interest after disasters and (b) designing studies in ways that maximize the potential for valid inference. We discuss these challenges - drawing on specific examples - and suggest potential approaches to each that may be helpful as a guide for future work. We further suggest research directions that may be most helpful in moving the field forward.

Suicidal ideation in college students varies across semesters: the mediating role of belongingness

The interpersonal-psychological theory of suicidal behavior (Joiner, 2005) proposes that the need to belong is fundamental; when met it can prevent suicide and when thwarted it can substantially increase the risk for suicide. We investigate one source of group-wide variation in belongingness among college students--changes in the social composition of college campuses across academic semesters--as an explanation for variation in suicidal ideation across the academic year. Our results indicate that in a sample of college students at a large southern state university (n = 309), suicidal ideation varied across academic semesters, with highest levels in summer compared to both spring and fall. Differences in suicidal ideation between summer and spring were, in large part, accounted for by belongingness. Theoretical, as well as practical, implications are discussed regarding mechanisms for seasonal variation in suicidal ideation.

Intentional injury mortality in the European Union: how many more lives could be saved?

OBJECTIVE

To explore the scope for reducing the number of intentional injury deaths, hypothesizing that all European Union (EU) countries are able to match the experience of the country with the lowest mortality rate for intentional injuries.

DESIGN

Intentional injury mortality data for the three last available years and denominator population estimates were obtained from the World Health Organisation mortality database for the 22 EU countries with more than one million population. To estimate the potential saving of lives, the yearly average age adjusted injury mortality rates were calculated. This issue done for children (0-14), adults (15-64), and elderly people (65 and over), both including and excluding deaths from undetermined cause.

MAIN OUTCOME MEASURES

Number of lives that might potentially be saved if all EU member states matched the lowest intentional injury rate reported by an EU member state.

RESULTS

Over 73% of all intentional injury deaths could have been avoided if all EU countries matched the country with the lowest intentional injury mortality rate. EU member states would have suffered about 600 fewer intentional injury deaths in children, about 40 000 fewer adult deaths, and over 14 000 fewer intentional injury deaths in the elderly. This amounts to over 55 000 lives in a single year.

CONCLUSIONS

Many lives lost through injury might be saved if all countries were to achieve the lowest intentional injury mortality rates reported in the EU. How this theoretical observation might be translated into practice needs to be further explored as the international variation in intentional injury mortality rates in the EU results from a range of factors.

The effect of the September 11 terrorist attacks on suicide and deliberate self-harm: a time trend study

Suicide rates may be affected by world news. Our objective was to investigate the possible impact of the terrorist attacks of September 11, 2001, on suicidal behavior in the Netherlands. There was evidence of an increase in rates of suicide and deliberate self-harm in the weeks immediately following the attacks. These findings contrast with Durkheim's (1897) original suggestion that suicide rates decline in times of war and outside threat but are in line with findings of increases in suicidal behavior after media coverage of lethal violence.