The International Handbook of Suicide and Attempted Suicide

The International Handbook of Suicide

and Attempted Suicide

Edited by Keith Hawton

Department of Psychiatry, Oxford University, UK and

Kees van Heeringen Department of Psychiatry, University of Gent, Belgium

Advisory Board

Robert Goldney Ad Kerkhof

Stephen Platt David Shaffer

Lil Traskman-Bendz

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Contents

About the Editors

List of Contributors

Preface

Introduction

PART I

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Keith Hawton and Kees van Heeringen

UNDERSTANDING SUICIDAL BEHAVIOUR

Suicide in the Western World Christopher H, Cantor

Suicide in Asia and the Far East Andrew T A. Cheng and Chau-Show Lee

Attempted Suicide: Patterns and Trends Ad J. E M . Kerkhof

Biological Aspects of Suicidal Behaviour Lil Traskman-Bendz and J. John Mann

The Psychology of Suicidal Behaviour J. Mark G. Williams and Leslie R. Pollock

Ethology and Suicidal Behaviour Robert D. Goldney

Psychiatric Aspects of Suicidal Behaviour: Depression Jouko K. Lonnqvist

Psychiatric Aspects of Suicidal Behaviour: Schizophrenia Marc De Hert and Jozef Peuskens

Psychiatric Aspects of Suicidal Behaviour: Substance Abuse George E. Murphy

ix

xi

xvii

1

9

29

49

65

79

95

107

121

135

vi CONTENTS

Chapter 10

Chapter 11

Chapter 12

Chapter 13

Chapter 14

PART I1

Chapter 15

Chapter 16

Chapter 17

Chapter 18

Chapter 19

Chapter 20

Chapter 21

Chapter 22

Chapter 23

Psychiatric Aspects of Suicidal Behaviour: Personality Disorders Marsha M. Linehan, Shireen L. Rizvi, Stacy Shaw Welch and Benjamin Page

Psychiatric Aspects of Suicidal Behaviour: Anxiety Disorders Christer Allgulander

Sociology and Suicidal Behaviour Unni Bille-Brahe

The Genetics of Suicidal Behaviour Alec Roy, David Nielsen, Gunnar Rylander and Marco Sarchiapone

Pathways to Suicide: an Integrative Approach Kees van Heeringen, Keith Hawton and J. Mark G, Williams

SUICIDE AND ATTEMPTED SUICIDE IN SPECIFIC POPULATIONS AND CIRCUMSTANCES

Suicidal Behaviour in Children: an Emphasis on Developmental Influences Cynthia R. Pfeffer

Adolescent Suicidal Behaviour: a General Population Perspective Erik Jan de Wilde

Adolescent Suicidal Behaviour: Psychiatric Populations Alan Apter and Ornit Freudenstein

Suicidal Behaviour among the Elderly Daniel Harwood and Robin Jacoby

Sexuality, Reproductive Cycle and Suicidal Behaviour Jose Catalan

Suicidal Behaviour and the Labour Market Stephen Platt and Keith Hawton

Repetition of Suicidal Behaviour Isaac Sakinofsky

Physical Illness and Suicidal Behaviour Elsebeth Nylev Stenager and Egon Stenager

Ethical and Legal Issues Antoon Leenaars and Colleagues

147

179

193

209

223

237

249

261

275

293

309

385

405

421

CONTRIBUTORS vi i

Chapter 24

Chapter 25

Chapter 26

PART 111

Chapter 27

Chapter 28

Chapter 29

Chapter 30

Chapter 31

Chapter 32

PART IV

Chapter 33

Chapter 34

Chapter 35

Chapter 36

Chapter 37

Chapter 38

Suicide and Violence Matthew K. Nock and Peter M. Marzuk

Suicide among Psychiatric Inpatients Manfred Wolfersdorf

The Impact of Suicide on Relatives and Friends Sheila E. Clark and Robert D. Goldney

THE TREATMENT OF SUICIDAL BEHAVIOUR

Pharmacotherapy of Suicidal Ideation and Behaviour Robbert J. Verkes and Philip J. Cowen

Psychotherapeutic Approaches to Suicidal Ideation and Behaviour Heidi L. Heard

General Hospital Management of Suicide Attempters Keith Hawton

Treatment Strategies for Adolescent Suicide Attempters Philip Hazel1

Treatment and Prevention of Suicidal Behaviour in the Elderly Diego De Leo and Paolo Scocco

Multidisciplinary Approaches to the Management of Suicidal Behaviour Kees van Heeringen

THE PREVENTION OF SUICIDE AND A'ITEMPTED SUICIDE

Prediction of Suicide and Attempted Suicide Robert D. Goldney

General Population Strategies of Suicide Prevention Rachel Jenkins and Bruce Singh

Prevention of Suicide in Psychiatric Patients Louis Appleby

Approaches to Suicide Prevention in Asia and the Far East R. Srinivasa Murthy

Suicide Prevention in Schools David Shaffer and Madelyn Gould

Suicide Prevention and Primary Care Konrad Michel

437

457

467

487

503

519

539

555

571

585

597

617

63 1

645

661

CONTENTS ... Vl l l

Chapter 39 The Role of Mass Media in Suicide Prevention Armin Schmidtke and Sylvia Schaller 675

Chapter 40

Chapter 41 Future Perspectives

Author Index

Subject Index

Volunteers and Suicide Prevention Vanda Scott and Simon Armson

Keith Hawton and Kees van Heeringen

699

713

725

74 1

About the Editors

Keith Hawton is Professor of Psychiatry at Oxford University and Consultant Psychiatrist to Oxford Mental Healthcare Trust at the Warneford Hospital in Oxford. He is Director of the Centre for Suicide Research at Oxford University Department of Psychiatry, where he is responsible for a broad programme of interdisciplinary research concerning the causes, treatment and prevention of suicidal behaviour. The work of Professor Hawton and his research team has particularly focused on suicidal behaviour in young people, the epidemiology of attempted suicide, specific occupations and other groups at risk of suicide, media influences on suicidal behaviour, and the development and evaluation of treat- ments for suicide attempters. He is a member of the International Academy for Suicide Research, the International Association for Suicide Prevention, the American Academy of Suicidology and the American Foundation for Suicide Prevention. In 1995 the International Association for Suicide Prevention presented him with the Stengel Research Award for his research on suicide prevention.

Kees van Heeringen is Professor of Psychiatry at the University of Gent, Chef de Clinique at the Department of Psychiatry of the University Hospital of Gent, and Director of the Unit for Suicide Research at the University of Gent, Belgium. He has carried out research on suicidal behaviour for many years in local, national and international projects and acts as a consultant for the development of national and international suicide prevention programmes. His research inter- ests are the epidemiology of suicidal behaviour and the study of the relationship between psychological and biological characteristics in the development of suicidal behaviour.

List of Contributors

Christer Allgulander, Karolinska Institute, Neurotec, Department of Clinical Neuroscience, Division of Psychiatry, M57, Huddinge University Hospital, S-141 86 Huddinge, Sweden

Louis Appleby, School of Psychiatry and Behavioural Sciences, Withing- ton Hospital, West Didsbury, Manchester M20 8LR, UK

Alan Apter, Department of Child and Adolescent Psychiatry, Sackler School of Medicine, Tel Aviv University, Geha Hospital, P O Box 102, Petach Tikva 49100, Israel

Simon Armson, The Samaritans, 10 The Grove, Slough, Berkshire S L l lQ8 UK

Unni Bille-Brahe, Unit for Suicidological Research, Tietgens A l l t 108,5230 Odense M, Denmark

Christopher H. Cantor, Australian Institute for Suicide Research and Prevention, Grifith University, Nathan, Queensland 41 11, Australia

Jose Catalan, Imperial College of Science, Technology and Medicine, University of London, Psychological Medicine Unit, Chelsea and West- minster Hospital, 369 Fulham Road, London SWlO, UK

Andrew T. A. Cheng, Division of Epidemiology and Public Health, Insti- tute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan

Sheila E. Clark, Department of General Practice, University of Adelaide, Adelaide 5005, South Australia

xii CONTRIBUTORS

John Connolly, St Mary’s Hospital, Castlebar, Ireland

Philip J. Cowen, Psychopharmacology Research Unit, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK

Marc De Hert, University Centre St Jozej Leuvensesteenweg 51 7, B-3070 Kortenberg, Belgium

Diego De Leo, Australian Institute for Suicide Research and Prevention, GrifJith University, Nathan, Brisbane, Queensland 41 11, Australia

Erik Jan de Wilde, Faculty of Social and Behavioural Sciences, Depart- ment of Clinical and Health Psychology, Leiden University, Pieter de la Court Building, Wassenaarseweg 52, PO Box 9555,2300 R B Leiden, The Netherlands

Marlene EchoHawk, Alcoholism and Substance Abuse Program, Indian Health Service, Headquarters West, 5300 Homestead Road, Albuquerque, NM 87110. USA

Ornit Freudenstein, Department of Child and Adolescent Psychiatry, Sackler School of Medicine, Tel Aviv University, Geha Psychiatric Hospital, PO Box 120, Petach Tikva 49100, Israel

Danute Gailiene, University of Vilnius, Traidenio 27, 2004 Vilnius, Lithuania

Robert D. Goldney, The Adelaide Clinic, 33 Park Terrace, Gilberton, South Australia 5081, and Department of .Psychiatry, University of Adelaide, Adelaide, South Australia 5005, Australia

Madelyn Gould, Columbia University College of Physicians and Surgeons and School of Public Health, and New York State Psychiatric Institute, PI Annex, 722 West 168th Street, New York, N Y 10032, USA

Daniel Harwood, Section of Old Age Psychiatry, University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK

Keith Hawton, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK

... CONTRIBUTORS X I I I

Philip Hazell, Discipline of Psychiatry, Faculty of Medicine and Health Sciences, University of Newcastle, Callaghan, New South Wales 2308, Australia

Zhao Xiong He, Guangxi Academy of Social Sciences, Nanning, Guangxi, People’s Republic of China

Heidi L. Heard, Department of Psychology, University of Washington, Seattle, WA 98195, USA

Robin Jacoby, Section of Old Age Psychiatry, University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK

Rachel Jenkins, W H O Collaborating Centre, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AE UK

Ad J.F.M. Kerkhof, Department of Clinical Psychology, Vrije Universiteit, De Boelelaan 1109,1081 HV Amsterdam, The Netherlands

Natalia Kokorina, Kemorovo State Medical Academy, N. Ostrovosky Street 23-33, 99 Kemerovo 650099, Russia

Chau-Shoun Lee, Department of Psychiatry, Lotung Poa-Ai Hospital, Lotung, Ilan, Taiwan

Antoon Leenaars, University of Leiden, The Netherlands, and 880 Ouel- lette Avenue, Suite 7-806, Windsor, Ontario, Canada N9A 1 C7

David Lester, Center for the Study of Suicide, RR41, 5 Stonegate Road, Blackwood, NJ 08012, USA

Marsha M. Linehan, Behavioral Research and Therapy Clinics, Depart- ment of Psychology, University of Washington, Seattle, WA 981 95-1525, USA

Jouko K. Lonnqvist, Department of Mental Health and Alcohol Research, National Public Health Institute, Mannerheimintie 166, SF-00300 Helsinki, Finland

Andrew A. Lopatin, Kemorovo State Medical Academy, N. Ostrovosky Street 23-33, 99 Kemerovo 650099, Russia

xiv CONTRIBUTORS

J. John Mann, Department of Neuroscience, New York State Psychiatric Institute, Columbia University, 1051 Riverside Drive, Box 42, New York, N Y 10032, USA

Peter M. Marzuk, Joan and Sanford I. Weill Medical College of Cornell University, New York, N Y 10021, USA

Konrad Michel, Psychiatrische Poliklinik, Universitatsspital, Murtenstrasse 21, CH-3010 Bern, Switzerland

George E. Murphy, Washington University, 4940 Children’s Place, St. Louis, M O 631 10-1 093, USA

R. Srinivasa Murthy, Department of Psychiatry, National Institute of Mental Health and Neurosciences, PO Box 2900, Bangalore 56 029, lndia

David Nielsen, Labaratory of Neurogenetics, National Institute of Alcohol Abuse and Alcoholism, Bethesda, MD, USA

Matthew K. Nock, Department of Psychology, Yale University, Box 208205, New Haven, CT 06520, USA

Benjamin Page, University of Colorado, Boulder, CO 80309, USA

Jozef Peuskens, University Center St Jozex Leuvensesteenweg 51 7, 3070 Kortenberg, Belgium

Cynthia R. Pfeffer, New York Presbyterian Hospital, Westchester Division, 21 Bloomingdale Road, White Plains, New York 10605, USA

Stephen Platt, Research Unit in Health and Behavioural Change, Univer- sity of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, UK

Leslie R. Pollock, Institute of Medical and Social Care Research, Univer- sity of Wales, Wheldon Building, Bangor LL57 2 W UK

Mario Rodriguez, Calle 5ta, nr 29404 entre 294Y 296, Santa Fe Plaza, Ciudad Habana, Codigo Postal 19100, Cuba

Alec Roy, Department of Veterans Affairs, New Jersey Health Care Systems, Psychiatry Service, Medical Center, 385 Tremont Avenue, East Orange, NJ 07018, USA

CONTRIBUTORS xv

Gunnar Rylander, Department of Psychiatry, Karolinska Institute, 171 77 Stockholm, Sweden

Shireen L. Rizvi, Behavioral Research and Therapy Clinics, Department of Psychology, Box 351525, University of Washington, Seattle, W A 981 95- 1525, USA

Isaac Sakinofsky, High Risk Consultation Clinic and Suicide Studies Programme, Centre for Addiction and Mental Health, Clarke Institute of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada M5T 1 R8

Marco Sarchiapone, Department of Psychiatry, Catholic University, Rome, Italy

Sylvia Schaller, Universitats-Nervenklinik, Fuchsleinstrasse 15, 0-97080 Wurzburg, Germany

Lourens Schlebusch, Faculty of Medicine, University of Natal, 71 9 Umbilo Road, Durban, South Africa

Armin Schmidtke, Universitats- Nervenklinik, Fuchsleinstrasse 15,D-97080 Wurzburg, Germany

Paolo Scocco, Department of Mental Health, ULSS no. 12 Veneziana, Mestre Venice, Italy

Vanda Scott, La Barade, 32330 Gondrin, Le Gers, France; formerly Director General, Befrienders International, London, UK

David Shaffer, Columbia University College of Physicians and Surgeons, and New York State Psychiatric Institute, Division of Child and Adolescent Psychiatry, PIAnnex, 722 West 168th Street, New York, N Y 10032, USA

Stacy Shaw Welch, Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, Seattle, W A 981 95-1525, USA

Bruce Singh, Department of Psychiatry, Faculty of Medicine, Dentistry and Health Science, University of Melbourne 3052, Australia

Elsebeth Nylev Stenager, Department of Social Medicine, Odense Muni- cipality, Tolderlundsvej 2, 5, DK-5000, Odense C, and Institute of Public Health, Odense University, Odense, Denmark

xvi CONTRIBUTORS

Egon Stenager, Esbjerg Centralsygehus, Esbjerg, and The Danish Multiple Sclerosis Registry, Rigshospitalet, Copenhagen, Denmark

Yoshitomo Takahashi, Tokyo Institute of Psychiatry, 124-21 Akebono, Tachikawa-shi, Tokyo 190, Japan

Lil Traskman-Bendz, Department of Psychiatry, University Hospital, S-221 85 Lund, Sweden

Kees van Heeringen, Unit for Suicide Research, Department of Psychia- try, University Hospital, De Pintelaan 185, B-9000 Gent, Belgium

Robbert J. Verkes, 333 Department of Psychiatry, University Hospital Nijmegen, PO Box 91 01,6500 H B Nijmegen, The Netherlands

Lakshmi Vijayakumar, 21 Ranjith Road, Kotturpuram, Madras 600085, India

J. Mark G. Williams, Institute of Medical and Social Care Research, University of Wales, Wheldon Building, Bangor LL57 2uvC: UK

Manfred Wolfersdorf, Bezirkskrankenhaus Bayreuth, Klinik fur Psychia- trie und Psychotherapie, Nordring 2, 95445 Bayreuth, Germany

Preface

The field of suicide and attempted suicide has attracted considerably increased attention in recent years. Several governments around the world have established suicide prevention programmes. A major reason for this has been the very large increase in suicide in young people, especially males, seen in many countries. Another is the increase in the numbers of people that are attempting suicide, again particularly among the young. Some of these non-fatal acts are intended to result in death, others are acts involving a suicidal message to communicate needs or achieve other ends, and many involve a mixture of motivational reasons. There is also increasing interest in suicidal behaviour in the elderly. Attention to this age group, which in most countries continues to have the highest rates of suicide, probably reflects greater recognition of the importance of depression in older people and the extent to which it can be treated successfully.

The increased attention to suicide and attempted suicide has resulted in a massive expansion in research, which has occurred on all fronts, including psychiatry, psychology, social sciences, biology and genetics. There has been a greater focus on risk in specific subgroups, defined according to demographic and diagnostic categories. More recently, with the recognition that risk factors for suicidal behaviour are often multi-dimensional, classical diagnostic bound- aries have been crossed in order to describe more precisely the characteristics of individuals at increased risk. There has also been more attention to develop- ment and evaluation of the effectiveness of psychological and pharmacological treatments for suicide attempters and to the complex and difficult challenges inherent in trying to evaluate the effectiveness of preventive strategies and initiatives.

The major stimulus to our preparing this Handbook has been the need to bring together, in an easily accessible form, the burgeoning amount of knowledge from research and experience about the causes of suicidal behaviour, and its treatment and prevention. We thought it essential that the book should cover the diverse range of important topics in the field. We also wanted the book to reflect the international nature of the problem of suicide and attempted suicide and there-

xviii PREFACE

fore invited contributors from many countries of the world. The fact that most are from countries in the Western World reflects the particular attention that is being paid to this problem in these countries. Now, however, there is increasing awareness that suicidal behaviour is a problem in many developing countries, as will become evident from the chapters focusing on the situation in Asia and the Far East. The contributors are leaders in the field, especially in research and/or development of prevention strategies. Each was asked to prepare chapters that included the main areas of knowledge in their assigned topics, to present information where possible for which there is a research evidence base, and also to take a broad approach that would reflect different viewpoints and models. We have taken a very active approach to our editorial responsibilities with the aim of producing what we hope is a comprehensive and integrated volume. We thank our contributors for their patience and for responding so positively to our suggestions.

Our ultimate aim has been to produce a Handbook that, as we enter the new millennium, will serve as an invaluable source of information for researchers, clin- icians and scholars from a wide range of disciplines, including psychiatry, psy- chology and the social sciences. We believe it will be an invaluable source for people starting out in this field of study as well as to experienced researchers. We hope that clinicians will find in it much of value and that policy makers will use it as an authoritative source of information relevant to formulation of local and national prevention strategies. Volunteers and counsellors will find much in the book to improve their knowledge base and skills. It will be an important refer- ence text for trainees in psychiatry, psychology, social work, psychiatric nursing and allied disciplines. Finally, we believe that, for people who have themselves been afflicted by suicidal inclinations and those who have experienced suicidal behaviour in people close to them, the book may provide understanding of the issues that lead to suicidal behaviour and the factors that can prevent it. We hope that the overall impact of this book will be to ensure that knowledge about suicide and attempted suicide is easily accessible, with consequent benefits for the advancement of thinking about research and prevention in this most impor- tant of fields concerning the quality and value of human life.

We wish to acknowledge the considerable support we have received in the preparation of this book from a range of individuals. These include Michael Coombs and Lesley Valerio at Wiley, who initially encouraged our interest in this project and supported us throughout. We also thank our families, who have had to endure our regular absences for editorial meetings in a range of locations, our secretaries, Members of the Advisory Board and our other colleagues in the field, who have encouraged us at times when our enthusiasm was on the wane. Lastly, but most importantly, we thank the contributors, who have put so much work into helping to bring this project to fruition.

Keith Hawton Kees van Heeringen

January, 2000

Introduction

Keith Hawton Department of PsychiatrF Oxford University, Oxford, UK

and Kees van Heeringen

Department of Psychiatry University Hospital, Gent, Belgium

It is estimated that worldwide between 500,000 and 1.2 million people die by suicide each year (United Nations, 1996). Non-fatal acts of deliberate self- poisoning or self-injury are many times more frequent, especially in young people. Suicidal behaviour is, therefore, an extremely important health and social issue throughout the world. This was a major reason for producing a compre- hensive book with an international focus.

This Handbook is about the causes, treatment and prevention of suicidal behaviour. However, the question of the extent to which suicidal behaviour actu- ally can be treated and/or prevented has justifiably and repeatedly been posed. Strikingly different answers to this question emerge from reviews of the litera- ture. Reviews of treatments and interventions aiming at reducing the occurrence of suicidal behaviour have led to rather disappointing conclusions, although methodological and ethical limitations of studies in this field need to be taken into account when interpreting the results of studies of the effectiveness of inter- ventions (Gunnel1 and Frankel, 1994; Wilkinson, 1994; Hawton et al, 1998). In view of such limitations, and given the fact that the effects of interventions, such as the elimination of means to commit suicide, cannot be assessed by means of conventional research methods, the use of alternative and innovative approaches at individual high-risk and population levels has been advocated. The results of a review of such approaches suggest more optimistic conclusions (Goldney, 1998).

Whether based on conventional research methodologies (such as randomized controlled trials) or on innovative methodologies, all approaches to the treatment of suicidal individuals and to the prevention of suicidal behaviour should be based on a thorough knowledge of causes and risk factors. A major contribution to this knowledge comes from epidemiological studies, in which the distribution of the occurrence of suicidal behaviour across the general population and the factors that influence this distribution are investigated. Substantial methodolog-

The International Handbook of Suicide and Attempted Suicide. Edited by K. Hawton and K. van Heeringen. 0 2000 John Wiley & Sons, Ltd.

2 K . HAWTON AND K. VAN HEERINGEN

ical controversies emerge in reviewing epidemiological studies in this field, including those associated with nomenclature and ascertainment procedures.

With regard to the issue of nomenclature, the terms “suicide” and “attempted suicide”, as used in the title of this book, refer to behaviours that share inten- tional or deliberate self-harming characteristics but differ with regard to the outcome, that is, whether or not they result in death. However, the use of the term “attempted suicide” has been criticized because of the fact that a vast major- ity of suicide attempts are not characterized by suicidal intent (i.e. a wish to die), and that attempts may vary widely with regard to other relevant characteristics, such as medical seriousness or the lethality of methods used to attempt suicide. We therefore need to stress that the term “attempted suicide” is used in this book to describe any self-injurious behaviour with a non-fatal outcome, irrespective of whether death was intended (see Chapter 3 for a further discussion of this issue). We are aware of the fact that this approach is partially in conflict with a recently proposed nomenclature for suicidology, in which the term “attempted suicide” is used to describe self-inflicted behaviours for which there is evidence that the person intended “at some level” to kill him/herself (O’Carroll et al, 1998). Our use of the term “attempted suicide” reflects a pragmatic approach, which is partly based on the fact that any motives or intent involved in self-injurious behaviours may be ambivalent and difficult to assess in an unequivocal way. Throughout the book the term “attempted suicide” will be used interchangeably with the term “deliberate self-harm”, referring to “deliberate self-poisoning” or “deliberate self-injury”, depending on the method used to attempt suicide. As such, an initial distinction should be made between “attempted suicide” and behaviours that have been called self-injurious and risk-taking behaviours with immediate (e.g. skydiving) or remote (e.g. smoking) risk (O’Carroll et al, 1998). Secondly, the term “attempted suicide” does not refer to self-injurious behaviours that may share characteristics of the so-called “deliberate self-harm syndrome” (Pattison and Kahan, 1983). This usually has an onset in late adolescence, involves multi- ple recurrent episodes of self-cutting or other similar damaging acts of low lethal- ity, and the behaviour often continues for many years. It has, however, been suggested since the 1970s that persons suffering from the deliberate self-harm syndrome may be at increased risk of committing suicide after many years of self-injurious behaviour (Morgan, 1979). Also, as will be discussed further in Chapters 14 and 21, more recent epidemiological research indeed indicates that many forms of self-harming behaviour may, in fact, occur along a continuum ranging from suicidal ideation to completed suicide.

The second issue to be considered when interpreting results from epidemio- logical research concerns the effect of differences in procedures of ascertainment of suicide between countries. The range of official ascertainment procedures is very wide. For example, in some countries possible suicides are investigated by the police, in others by medical practitioners, and in yet others by coroners or their equivalents. Each approach is likely to be limited by biases of one kind or another, most of which result in an underestimate of suicide rates, because there is a general tendency towards not reaching a verdict of suicide rather than the

INTRODUCTION 3

reverse. This may reflect, first, a wish to avoid upset to families; second, national religious and cultural values; and third, ignorance of the extent and heterogene- ity of suicidal acts. Crude rank order comparison of national suicide rates does, however, appear to reflect real differences (Sainsbury, 1983), although the absolute levels may be misleading. If influences on ascertainment procedures change, this can result in spurious changing trends in suicidal behaviour. This appears to have been the case to some extent in Ireland (see Chapter l), although the rising recent suicide rate there also appears to reflect a real underlying trend. Interpretation and study of cross-national suicide rates would be greatly aided if there were more consistency in ascertainment procedures. The WHO/EU Mul- ticentre Study on Parasuicide (see Chapter 3) represents a recent encouraging effort to achieve this for non-fatal suicidal behaviour, in which ascertainment is possibly even more hazardous because of definition issues and problems of case identification.

Part I of this Handbook begins with three chapters in which the epidemiol- ogy of suicide and attempted suicide in countries throughout the world is examined in detail. These are followed by overviews of models that have been developed to understand suicidal behaviour. Individual chapters are devoted to each of the three ‘‘classical’’ approaches, that is the psychological, biological and sociological. There is a further chapter in which an ethological perspective on the link between early psychodynamic hypotheses and biological formulations of sui- cidal behaviour is described. Findings from genetic and, more recently, molecu- lar biological research, add to these models the possibility of a genetically defined predisposition to suicidal behaviour, which may run across the boundaries between psychiatric disorders. As demonstrated in Chapters 7 to 11, in which the occurrence of suicide and attempted suicide in people suffering from depressive disorders, schizophrenia, personality disorders, anxiety and substance abuse disorders are examined, longitudinal investigations and psychological autopsy studies have indeed indicated that suicidal behaviour may occur within the context of diverse psychiatric disorders. In the concluding chapter of Part I an attempt is made to integrate the findings from epidemiological, biological, psychological, ethological, psychopathological and sociological investigations. This shows how early hypotheses have evolved into cognitive psychological and biological models that may serve as a robust basis for the treatment of suicidal behaviour and further research in this field.

Part I1 of this book is dedicated to the description of populations and cir- cumstances in which suicidal behaviour may occur, or which may be affected by the occurrence of suicidal behaviour. The detailed description of these popu- lations and circumstances can further help us in understanding suicidal behav- iour, and point to issues that require specific attention. As was shown in Part I, there is an urgent need for specific attention to young people, as rates of suici- dal behaviour among them are strongly increasing in most parts of the globe. The initial chapters in Part I1 are dedicated to the description of developmental pathways and psychopathological characteristics of suicidal behaviour among children and adolescents. From the studies that are reviewed it is clear that the

4 K. HAWTON AND K. VAN HEERINGEN

characteristics of suicidal youngsters in the general population closely resemble those of suicidal young people in treatment settings. This suggests that many adolescents in the general population may be in need of help, the more so as almost any diagnosable psychiatric disorder is a major risk factor for youth suicide.There follows a chapter focused on the other end of the age span, in which risk factors for suicidal behaviour among the elderly are described. Specific populations and circumstances associated with suicidal behaviour are discussed in other individual chapters in this part of the book. A chapter on sexuality and the reproductive cycle examines the risk of suicidal behaviour in homosexual populations, during pregnancy and following childbirth or stillbirth, and in in- dividuals with deviant sexual behaviour. Suicide and attempted suicide rates vary with employment status and occupation, and these associations are examined in a chapter on suicidal behaviour and the labour market. It has long been recog- nized that physical illness is linked to risk of suicidal behaviour, and this is described in detail in the next chapter. Risk of suicide is a major reason for admission to psychiatric inpatient care. This means that in psychiatric units there is a high concentration of people at risk. In spite of intensive preventive efforts, suicides do occur in this setting and a chapter is devoted to examination of the extent and nature of suicidal behaviour in psychiatric units. The impact of suicide on relatives and friends is usually highly traumatic. A chapter is therefore focused on the specific experiences of people who suffer such a loss and ways in which they can be helped. One of the most important features of suicidal behaviour is that it is often repeated, not infrequently with a fatal outcome. In the subsequent chapter, the problem of repetition of suicidal behaviour and factors associated with it are, therefore, examined in depth. A host of important legal and ethical issues surround suicide and attempted suicide. As these differ between countries a chapter is devoted to their examination from an international perspective. There are strong links between suicidal behaviours and both aggression and violence. These associations, including suicide associated with homicide, suicide pacts, and suicidal behaviour in prisons, are explored fully in the subsequent chapter. The findings from the studies reviewed in these chapters further refine the description of the social, biological and psychological characteristics that are associated with suicidal behaviour, and constitute the fundamentals of the approaches to treatment and prevention as described in Parts 111 and IV of this Handbook.

Perhaps the most difficult area in suicidological research concerns the study of the effectiveness of interventions to reduce the occurrence of suicidal be- haviour. The fact that the results of such studies have, in general, been rather disappointing may reflect our limited knowledge of pathogenic mechanisms underlying suicidal behaviour, but may also be attributable to methodological issues, such as small sample sizes and patient selection. While conventional treat- ment strategies focus on categorically defined psychiatric disorders, such as depressive disorders, and thus may contribute to the prevention of suicidal behav- iour, it is suggested that the effectiveness of interventions may benefit further from addressing the specific psychological, biological and behavioural character- istics of the patient population. This should include attention to the problems of

INTRODUCTION 5

poor compliance and engagement with treatment that many of these patients show. There have been recent promising findings from studies of psychophar- macological and psychotherapeutic approaches, using selective serotonin re- uptake inhibitors and dialectical behaviour therapy, respectively. Two chapters in this part of the Handbook focus on service issues, particularly management of patients in the general hospital following presentation for deliberate self- poisoning or self-injury, and the assessment and treatment of attempted suicide patients by staff from a range of professional backgrounds, including nurses, social workers and general physicians. Two further chapters in Part 111 review in detail studies that have evaluated the efficacy of the treatment of suicidal ideation and behaviour in adolescents and the elderly. The final two chapters in Part 111.

Part IV of the Handbook is dedicated to the prevention of suicide and attempted suicide. With regard to prevention approaches, a general distinction has to be made between high-risk and population strategies (Lewis et al, 1997). The first chapter provides an overview of the currently available knowledge about the prediction of suicidal behaviour, indicating that our limited ability to predict suicidal behaviour among the many who are suicidal should be taken into account as a limiting factor in the former approach. In view of the demonstrated association between suicidal behaviour and psychiatric disorders, as described in Part I, psychiatric patients can be regarded as constituting a high-risk group, usually based, however, within the general population. The effective prevention of suicide in these patients may, therefore, require a combination of high-risk and population approaches. Components of such general population strategies are described in two chapters by means of discussion of initiatives which have been developed in the Western world and in Asia and the Far East, respectively. While such programmes in different parts of the world can probably include common strategies, it is also emphasized that characteristics related to local culture and the organization of mental health care have to be taken into account. In a further chapter, school-based suicide prevention programmes and their evaluation are described. One chapter addresses an important component in a population- based strategy, but which includes a high-risk element, namely improving general practitioners’ detection and management of psychiatric disorders, especially depression, that are associated with suicide risk. Another chapter examines the contribution of media portrayal of suicidal acts to the spread of suicidal behav- iour in the population, with suggestions about how media approaches might be modified to reduce the risk of imitative behaviour. There follows a chapter which explores the important role of volunteer organizations in prevention of suicidal behaviour. In the concluding chapter of the Handbook, future perspectives regarding potentially fruitful developments in research, clinical practice and prevention are outlined.

REFERENCES

Goldney, R.D. (1998) Suicide prevention is possible: a review of recent studies. Archives of Suicide Research, 4: 329-339.

6 K. HAWTON AND K. VAN HEERINGEN

Gunnell, D. and Frankel, S. (1994) Prevention of suicide: aspirations and evidence. British Medical Journal, 308: 1227-1233.

Hawton, K., Arensman, E.,Townsend, E., Bremner, S., Feldman, E., Goldney, R., Gunnell, D., Hazel], P., van Heeringen, K., House, A., Owens, D., Sakinofsky, I. and Traskman- Bendz, L. (1998) Deliberate self-harm: a systematic review of the efficacy of psychosocial and pharmacological treatments in preventing repetition. British Medical Journal, 317: 441447.

Lewis, G., Hawton, K. and Jones, P. (1997) Strategies for preventing suicide. British Journal of Psychiatry, 171: 351-354.

Morgan, H. (1979) Death Wishes? The Understanding and Management of Deliberate Self-harm. Chichester: Wiley.

O’Carroll, PW., Berman, A.L., Maris, R., Moscicki, E., Tanney, B. and Silverman, M. (1998) Beyond the Tower of Babel: a nomenclature for suicidology. In R.J. Kosky, H.S. Eshkevari, R.D. Goldney and R. Hassan (Eds), Suicide Prevention: the Global Context, pp. 23-39. New York: Plenum.

Pattison, E.M. and Kahan, J. (1983) The deliberate self-harm syndrome. American Journal of Psychiatry, 140 867-872.

Sainsbury, P. (1983) Validity and reliability of trends in suicide statistics. World Health Statistics Quarterly, 36: 339-348.

United Nations (1996) Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies. New York: United Nations.

Wilkinson, G. (1994) Can suicide be prevented? British Medical Journal, 309: 86G862.

Part I

Understanding Suicidal Behavioui

Chapter I

Suicide in the Western World

Christopher H. Cantor Australian Institute for Suicide Research and Prevention,

Griffith University, Brisbane, Australia

Abstract

International perspectives on suicide have tended to compare diverse nations with little consideration of whether the comparisons were worthwhile. This chapter narrows the international focus by comparing suicide rates in the Western World, with only passing mention of other countries. New data on Western suicide rates are presented with con- sideration of the cultural and geographical similarities and dissimilarities. The most significant recent trends have been increased suicide rates in young males in many coun- tries, especially those in the New World and in several countries in Western Europe. Trends in methods of suicide seem to have reflected changes in both their availability and acceptability. Substantial progress with respect to studies of methods of suicide is also summarized. Marital status, parenthood and suicide is presented, as these issues have been relatively neglected. Examination of the associations of seasons and weather with suicidal behaviour is also included. The chapter concludes with more general speculation about reasons for secular trends and suggestions for future research.

INTRODUCTION

Epidemiology is concerned with distributions of disease and factors that influ- ence distribution. Suicide is a behaviour-not a disease. Nevertheless, epidemio- logical approaches are of value to the understanding of suicide. While disease patterns may be influenced by cultural factors, including alcohol consumption, cigarette smoking and sanitation, behaviours like suicide are more open to cul- tural influences, including, for example, modelling of suicide via the mass media (see Chapter 39) and inhibition of suicide by religious influences.

The reliability of international suicide data is highly variable. Nevertheless, a World Health Organization (WHO, 1982) working group and others (Sainsbury

The international Handbook of Suicide and Attempted Suicide. Edited by K. Hawton and K. van Heeringen. 0 2000 John Wiley & Sons, Ltd.

10 C. H. CANTOR

and Barraclough, 1968) expressed confidence in the use of international suicide statistics. Within the Western world, Schmidtke (1997) has commented on the dif- ferent European death registration practices-for example, the Coroner-based system of the UK contrasts with that of Germany, which permits general prac- titioner certification. In Australia there are eight different systems, correspond- ing to the six states and two territories. International comparisons are valuable but must consider the influences of varying data collection systems.

HISTORY AND CULTURE

The history of suicide was until recently dominated by the determination of intent, which was important for consideration of punishment of an individual or hidher family for such acts. Persecution of families bereaved by suicide was offi- cially sanctioned, even in progressive European countries, until it was outlawed as late as the eighteenth Century (Colt, 1987). In most Western countries suicide attempts were decriminalized only in the 1960s and 1970s. Cultural attitudes have changed from those of persecution to more diverse orientations that are still in states of flux. While suicide in most countries is no longer illegal, certain religious influences act as deterrents. Islamic and Catholic religions strongly disapprove of suicide and suicide rates in countries adhering to orthodox teachings tend to be low. Conversely, certain aspects of modern youth culture, for example heavy metal music, tend to portray suicide in positive terms. Lay people tend to over- estimate the extent of rational suicide and underestimate the consequences of suicide on loved ones. Morality is a topic mental health professionals rightly are reserved about. Nevertheless, moral attitudes are of relevance to the epidemiol- ogy of suicide. Ideally, moral attitudes might differentiate and understand diverse motivations for suicide, including mental illness, rational self-euthanasia and the desire to hurt others.

INTERNATIONAL COMPARISONS

Epidemiological reviews have often presented suicide rates from diverse nations selected on the basis of data availability. Diversity may obscure observations that might be evident if more homogenous nations were studied. There is no reason to expect that suicide rates in a thriving developed nation would conform with those of a culturally different developing nation. Consequently, former Eastern bloc nations that might be considered “Western” are not included in the com- parisons that follow, as their social environments are still quite different from the West and are undergoing rapid change which in itself might influence suicide rates. Generally, Eastern European suicide rates are substantially higher than those of Western Europe and have risen in recent years (Sartorius, 1996). Between 1987 and 1991-1992 suicide rates in Eastern European countries increased, in contrast to decreases in other European countries. Also, the male: