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Institute of Medicine (US) Board on Neuroscience and Behavioral Health. Risk Factors For Suicide: Summary of a Workshop. Washington (DC): National Academies Press (US); 2001.

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Risk Factors For Suicide: Summary of a Workshop.

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SOCIAL AND CULTURAL FACTORS IN SUICIDE RISK

Dr. Ronald Maris advocated the need for multi-disciplinary studies of suicide in order to develop an integrated causal model that includes biological, psychological, and social factors. In his talk, he briefly reviewed social and cultural factors, including age, sex, race, ethnicity, social isolation, contagion, and religion.

Dr. Maris quickly summarized group differences in suicide rates. There are large differences in suicide rates across race, sex, age, and ethnicity. These differences may be informative for identifying risk and protective factors. The relative risk of a white male versus a black female suicide, controlling for age, is almost 10 to 1. Comparing rates for the oldest sub-population of each group, this ratio rises to 18 to 1. Data from the Epidemiologic Catchment Area Study indicate that black women attempted suicide at about the same rate as white women, but had fewer completions. They were distinguished from white females by having more social supports, larger extended families, more religious proscription against suicide, stronger mothering ethos, and fewer visits to the doctor.

African-American women, particularly in midlife, are virtually immune to suicide.

Ronald Maris

In the United States, male suicide rates are about 4.5 times that of females. “These gender ratios do not persist internationally, suggesting the influence of social and cultural factors,” Dr. Maris stated. The relative risk for male-female suicides for the ages of 55 to 64 is 7.9 in Singapore and 1.8 in Bejing. Hungary has the highest national suicide rate in the world at 66 per hundred thousand. Finland and Austria are next highest, with rates of 43 and 42 respectively, as compared the U.S. rate of 10–12 per hundred thousand. Dr. Maris stated that “most of these high suicide rate countries have higher rates of depressive disorder, high levels of alcohol consumption, often apart from rituals or food intake, a greater relative proportion of an older population, more social isolation, more cognitive rigidity and inflexibility…”

Some nations report very low suicide rates; for example the rate in Mexico is 2.5 per 100,000, which is about 26 times lower than Hungary. Countries with low suicide rates tend to be predominantly Catholic or Muslim, are typically relatively youthful, have strong social control networks, more extended family ties, and explicit proscription of suicide. In some cases countries with lower suicide rates also have lower rates of depression. Dr. Maris mentioned that some cultures do not stigmatize suicides under particular circumstances such as loss in battle, acute and mortal infirmity, and sacrifice for the physical and/or economic survival of others.

…Most social involvement is negatively correlated with the suicide rate.

Ronald Maris

Dr. Maris discussed the effect of social isolation on suicide rates. He reported suicide outcome is enhanced by the loss of necessary social supports, increases in hostility and aggression, the corresponding reduction of targets for the aggression other than oneself as occurs in jail, greater impulsivity resulting from fewer social constraints, and isolation-enhanced depression, sleep disorder, and hopelessness. Dr. Maris found a significant negative correlation between population per household and suicide rate in a survey study in Chicago. Follow-up work in Chicago revealed that the natural death controls had twice as many close friends than the suicide cases on average. Dr. Maris described an earlier study that also found suicide rates to be correlated with indices of limited social contact such as living alone and being divorced.

On the other hand, some social relationships increase suicide risk. Stress from relationship difficulties can precipitate suicide. Other special social circumstances influence suicide such as cult suicides, homicide-suicides, and kamikaze pilots in World War II.

Dr. Maris went on to discuss the issue of suicide contagion. Suicides in adults increase approximately 2 to 3 percent for 7 to 10 days following published suicide stories due to contagion, according to data cited by Dr. Maris. Suicides of entertainers and celebrities are copied, but those of artists, the economic elite, or villains are not. Other data have shown additional influences on contagion. Similarities in demographics between the stimulus suicide and those who may imitate increases the risk. Teenagers are approximately twice as likely to imitate a stimulus suicide than adults.

The more the stimulus suicide is praised, glorified, or rewarded, the more likely the copying will occur.

Ronald Maris

Dr. Maris noted that religion is a neglected topic in suicide risk. In the United States government documents such as the census and death certificates are required by law to omit religious information, making systematic study of the role of religion in suicide risk difficult. There is a general assumption that involvement in many world religions reduces suicide risk, especially for religions that teach eternal damnation for those who commit suicide. In Chicago and New York City Dr. Maris found that Protestants had approximately double the suicide rates of Catholics after controlling for race, sex, and age. Yet Hungary and Austria, predominantly Catholic countries (68 and 90 percent, respectively) have among the highest suicide rates in the world. One possible explanation for these disparate findings is that suicide is reduced by religious involvement and participation in rituals and ceremonies, not simply by affiliation. Dr. Maris's research on religion and suicide found that non-suicidal males were more than twice as likely to attend church on Christmas as those who committed suicide, regardless of denomination.

Dr. Mann emphasized Dr. Maris' comments on the complexity of religious beliefs on suicide. He gave the example that in Judaism, self-murder is only defined as suicide in the absence of significant psychosocial stressors or mental illness. Yet the majority of self-identified Jews do not know this technical distinction, and believe all suicides are prohibited by Jewish law.

Dr. Kleinman stated that the Confucian Asian countries such as China, Japan, and Vietnam, have higher suicide rates than non-Confucian Asian societies. Those with a significant Buddhist component often have lower rates, but these are very sensitive to macro-social circumstances. For example, the Sinhalese in Sri Lanka had one of the world's lowest suicide rates, but after 20 years of political violence they now have a very high suicide rate. Similarly, in Thailand and other southeast Asian nations, the suicide base-rate was low, but then increased with political destabilization and major economic change at the macro level.

Finally, Dr. Maris discussed suicide risk in incarcerated populations. Dr. Maris reported that in jail, and to a lesser degree in prison, suicide occurs most frequently among new arrivals (58 percent of prison suicides occurring with 48 hours of confinement; 29 percent in the first three hours). Most commonly, those who commit suicide are male (95 to 100 percent), meet the criteria for antisocial personality disorder, and have affective and/or anxiety disorders (67 percent). Often they are isolated from other inmates. Cognitive impairment is low, and most are not psychotic. Prison suicides tend to have histories of early and continuing substance abuse, primarily alcohol. Standard fifteen minute intervals between checks are not sufficient since the most common methods of suicide by incarcerated persons is hanging or asphyxiation, which can occur in as little as 6 minutes.

Suicide is the leading cause of death in the U.S. jails and prisons…

Ronald Maris

Dr. Maris listed ways to reduce jail and prison suicides: (1) do not isolate inmates; (2) increase staff watch for the first three hours of confinement; (3) increase frequency of visual checks, possibly by video camera; (4) remove all dangerous items; (5) increase checks after significant life-changes (e.g., changes in housing status or sentencing, major relationship changes such as divorce or change in attorney or key staff, or parole denial); (6) increase watch during meals and weekends when suicide tends to increase; (7) diagnose and treat psychiatric conditions; (8) increase observation of young males, especially those who are belligerent and/or intoxicated; (9) educate staff in proper emergency responses and; (10) assess suicide risk. Dr. Maris underscored that proper assessment of suicidality is rare.

Copyright 2001 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK223752

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