Suicide Prevention

Suicide Preve n tio n
A review of evide n c e of risk and prot e c tiv e factors, and points of effective interv e n tion
Citation: Beautrais AL, Collings SCD, Ehrhardt P, et al. 2005. Suicide Prevention: A review of evidence of risk and protective factors, and points of effective intervention . Wellington: Ministry o !ealth. Pu"lished in May 2005 "y the Ministry o !ealth P# Bo$ 50%&, Wellington, 'e( )ealand *SB' 0+,-.+ 2.&-/+ . 0Boo12 *SB' 0+,-.+ 2.&--+ / 0*nternet2 !P ,%%0 3his do4u5ent is a6aila"le on the Ministry o !ealth7s (e"site: htt8:99(((.5oh.go6t.n:
Cont e n t s
Contents .............................................................................................iii
Dis4lai5er ............................................................................................................................. 6 Authors .................................................................................................................................. 6
*ntrodu4tion ........................................................................................%
3he e$tent o the 8ro"le5 ................................................................................................. % An histori4al 8ers8e4ti6e ................................................................................................... 2 S4o8e ..................................................................................................................................... , Stru4ture o the re8ort ....................................................................................................... 5
% 3i5e 3rends and E8ide5iology .................................................../

3i5e trends in 'e( )ealand sui4ide rates, %;50 2002 ............................................../ <ender di eren4es ............................................................................................................. . Age di eren4es .................................................................................................................... . Ma=or 4auses o death ...................................................................................................... %% Sui4ide rates "y ethni4ity ................................................................................................ %2 *nternational 4o58arisons o sui4ide rates ..................................................................%, !os8italisation or sui4ide atte58t ...............................................................................%3rends in 5ethods o sui4ide and sui4ide atte58t ....................................................%. Po8ulations at high ris1 or sui4ide and sui4ide atte58t ..........................................%;
2 >is1 ?a4tors ...................................................................................2,

Mental disorders ............................................................................................................... 2, Mental health a4tors ....................................................................................................... 2. Psy4hologi4al ris1 a4tors ................................................................................................&0 'euro"iologi4al ris1 a4tors ............................................................................................ &2 Childhood ad6ersity ......................................................................................................... && Psy4hoso4ial stresses ....................................................................................................... &, So4ial and de5ogra8hi4 a4tors ....................................................................................&5 So4ial a4tors rele6ant to sui4ide 8re6ention in 'e( )ealand .................................,0
& >esilien4y and Prote4ti6e ?a4tors .............................................,& , Cultural *ssues ..............................................................................,.

M@ori .................................................................................................................................... ,. Pa4i i4 8eo8les ................................................................................................................... 50 Peo8le o *ndian des4ent .................................................................................................5% Asian 8o8ulations ............................................................................................................. 5% >e ugee grou8s ................................................................................................................. 52 De6elo8ing 4ulturally a88ro8riate sui4ide 8re6ention ser6i4es ..............................52
5 A4tions to >edu4e and Pre6ent Sui4ide ...................................5,
Suicide Prev e n ti o n A revie w of evide n c e of risk and prote c tiv e facto rs , and points of effe ctiv e interv e n ti o n
iii
Points o e e4ti6e inter6ention ......................................................................................5Si5ilarities and di eren4es in 8ers8e4ti6es ................................................................5;
/ Con4lusions .................................................................................../2 A88endi$: E8ide5iologi4al Data Sour4es .................................../, >e eren4es ......................................................................................./5
List o 3a"les
3a"le %: 'e( )ealand leading 4auses o death, "y age grou8, 2000 ..............................%%
List o ?igures
?igure %: 'e( )ealand age+ ad=usted sui4ide rates, %;50A2002 ........................................../ ?igure 2: 'e( )ealand sui4ide rates, "y se$, %;50 2002 ....................................................?igure &: 'e( )ealand youth 0%5 2, years2 sui4ide rates, "y se$, %;50 2002 ................ ?igure ,: 'e( )ealand age+ s8e4i i4 sui4ide rates, %;50 2002 ...........................................; ?igure 5: Sui4ide rates, "y age and se$, 'e( )ealand, 2002 ............................................%0 ?igure /: Per4entage o total 5ortality a44ounted or "y sui4ide, "y age and se$, 200% .................................................................................................................................... %% ?igure -: M@ori and non+ M@ori sui4ide rates, total 8o8ulation, "y se$, %;;/ 2002 .....%& ?igure .: M@ori and non+ M@ori youth 0%5 2, years2 sui4ide rates, "y se$, %;;/A200% .................................................................................................................................... %& ?igure ;: 3otal 5ale sui4ide rates or sele4ted #ECD 4ountries .......................................%, ?igure %0: 3otal e5ale sui4ide rates or sele4ted #ECD 4ountries ..................................%5 ?igure %%: Male youth sui4ide rates 0%5 2, years2 or sele4ted #ECD 4ountries ..........%5 ?igure %2: ?e5ale youth sui4ide rates 0%5A2, years2 or sele4ted #ECD 4ountries ......%/ ?igure %&: Sui4ide and sel + in li4ted in=ury hos8italisation rate, 200%902 .......................%?igure %,: Methods o sui4ide, "y gender, 2002 ..................................................................%.
iv
Disclaim e r
In respo n s e to the incre a s e s throu g h to the late 1990 s in New Zeala n ds youth suicide rate s , the In Our Hands New Zealand Youth Suicide Prevention Strategy was dev elo p e d , and launch e d in 1998 !o supp ort and infor" the dev elo p " e n t and pu#lic discus sio n aroun d that stra t e g y, two report s were co" "is sio n e d to review the evide n c e on suicide 1 $ince the pu#lication of the original review report s, ther e has #e e n a su#s t a n ti al growth in the nation al and intern a tio n al literat u r e on the su#%ect of the caus e s and prev e n tio n of suicide, and e&pla n a tio n s for the chan gin g tren d s in suicide rat e s in the 'est e r n world ( including New Zeala n ds 'ith the "ov e toward s an all)age appro a c h to suicide prev e n tio n in New Zeala n d , and given the su#s t a n ti al growth in the litera t u r e , the *inistry of +ealth contr a c t e d an upd a t e review of the evide n c e to #e und e r t a k e n ,uring the prep a r a tio n of the review, and the dev elop " e n t of draft New Zeala n d $uicide $trat e g y ( A -ife 'orth -iving, it has #eco " e o#vious that, as with "a n y co"pl e& are a s of healt h relat e d study, the evide n c e for the caus e s and prev e n tio n of suicide is very divers e and su#%ect to a lot of de# a t e a#ou t which pers p e c tiv e has "or e "erit than anot h e r , and wher e the focus for prev e n tio n should lie !his report was prep a r e d und er contr a c t to the New Zeala n d *inistry of +ealth !he copyrigh t in this article is owne d #y the .rown and ad "inist e r e d #y the *inistry !he views of the aut hor s do not nec e s s a rily repr e s e n t the views or policy of the New Zeala n d *inistry of +ealth !he *inistry "ak e s no warra n t y, e&pr e s s or i"plied, nor ass u " e s any lia#ility or res po n si#ility for use of or relianc e on the cont e n t s of this
Authors
A- /eautr ais, .ant er # u r y $uicide 0ro%ect, .hristch u rc h $chool of *edicine and +ealth $cienc e s $., .ollings, ,ep art " e n t s of 0sychological *edicine and 0u#lic +ealth, 'ellingto n $chool of *edicine and +ealth $cienc e s 0 1hrhar d t, +enar e 1hrhar d t 2es e a r c h 3 +enar e , +enar e 1hrhar d t 2ese a r c h
A Review of Evidence: In Our Hands the New Zea and !outh Suicide Prevention Strate"# "y Annette Beautrais e$a5ined the e6iden4e "ehind the a88roa4hes in In Our Hands . 3he se4ond re8ort, A Review of Evidence: $ia Piki te Ora o te %aita&ariki the New Zea and !outh Suicide Prevention Strate"# (as (ritten "y Beri La(son+ 3e Aho and 8ro6ided the "asis or 8re6ention o MCori youth sui4ide. 3hese re8orts are a6aila"le ro5 the Ministries o !ealth and Douth A airs and 3e Puni BE1iri.
Introduc tio n
The exten t of the proble m
In rece n t year s suicide has e" e r g e d as an i"port a n t pu#lic he alth pro#le " in "a n y countrie s 43rug et al 50056 Intern a tio n ally, appro&i " a t e l y one "illion peopl e die #y suicide eac h year 4'+7, 19996 In New Zeala n d al"os t 800 peopl e die #y suicide ann u ally "ore than die in road traffic accide n t s and ho"icid e s co"#in e d $ince 1980 ther e hav e #ee n "or e than 19,00 0 suicide s in New Zeala n d , and suicide is the secon d "os t co" " o n reas o n for de a t h a"o n g youth and youn g adults age d 18 :; 4NZ+I$ 500;6 *ore positively, in the last five years 41998 50056 ther e has #ee n a 58 perc e n t reduc tio n in the rat e of suicide in New Zeala n d , fro" 1; : to 10 9 per 100,0 0 0 It has #e e n esti" a t e d that ther e are fro" 8 to 58 ti"e s as "a n y suicide att e " p t s as suicide dea t h s 4*oscicki 50016 $uicide att e " p t s rang e in inten t and "e dic al sev erity fro" the "ildly self) in%urious to the det er "i n e dly leth al *ore tha n 8000 people pres e n t to e" e r g e n c y dep a r t " e n t s in New Zeala n d eac h year with "e dic ally significan t suicide att e " p t s 4NZ+I$ 500;6 At a pers o n al level, all suicide att e " p t s , reg ar dl e s s of the e&t e n t of "e dic al sev erity, are indications of sev er e e"o tion al distre s s , unh a p pin e s s and<or "e n t al illness $uicide and suicide att e " p t s place a stron g e"o tion al #urd e n on fa"ilies and friends !here are also su#s t a n ti al econo "ic costs associa t e d with lives lost to suicide !hes e costs arise fro" #er e a v e " e n t #y suicide, fro" the "e dic al and "e n t al health costs associa t e d with suicide att e " p t s , and fro" the #urd e n to fa"ily and wh nau who care for thos e who hav e "a d e suicide att e " p t s Althoug h the pers o n al, fa"ilial, social and econo "ic cons e = u e n c e s are serious, #ec a u s e suicide is a statis tic ally rare eve n t it is difficult to predict which individuals will die #y suicide !his unpr e dict a #ility is a pro#le " #ec a u s e , while ther e is a #roa d intern a tio n al cons e n s u s that "a n y suicide dea t h s are prev e n t a # l e , ther e are no clear ways in which it is possi#le to predict and prev e n t suicidal #eh a vio ur at an individu al level !o addr e s s suicide prev e n tio n "a n y countrie s hav e dev elop e d , or are dev elo ping, nation al suicide prev e n tio n strat e gi e s to provid e a fra " e w o rk for reducing the nu "# e r of suicides and suicide att e " p t s In rece n t year s the e"p h a s i s in New Zeala n d policy in suicide prev e n tio n has #ee n al"o s t e&clusiv ely in the are a of yout h suicide !his report contri#ut e s to work #eing und er t a k e n to dev elop a co"pr e h e n s iv e nation al suicide prev e n tio n stra t e g y for people of all age s !he report provid e s an overview of risk and prot e c tiv e factors, and points of effectiv e interv e n tio n, for suicide prev e n tio n in New Zeala n d , and provid e s a #ackgro u n d and resourc e to infor" the dev elo p " e n t of a nation al stra t e g y
An historical persp e c ti v e
$uicide res e a r c h has a long history 4>oldn e y and $chiolda n n 5000? 5001? 500;6 which has centr e d on a nu "# e r of theor e tic al "od els which includ e d sociocultur al, psycholo gic al, psycho a n a l ytic and "or al pers p e c tiv e s In the last two dec a d e s intern a tio n al res e a r c h into suicide has incre a s e d e&po n e n ti ally *uch of this rece n t res e a r c h has #ee n dev elo p e d in an ath e o r e tic al, e"pirical fra" e w o rk in which inves tig a t o r s hav e e&a "i n e d the role of likely caus e s and risk factors for suicidal #eh a viour 2ece n t contri#ution s to knowled g e a#ou t suicide hav e co" e fro" a nu" # e r of discipline s including psychia tric epid e "iolog y, #eh a viour al gen e tics and in%ury prev e n tio n !hes e various historical and rece n t influenc e s hav e contri#ut e d to, and sha p e d , the "od e r n "ulti) disciplinary field of suicide interv e n tio n and prev e n tio n In the latter half of the 50th cent ur y knowled g e a#ou t suicide was shap e d #y contri#ution s fro" thre e discipline s in particular $hneid " a n 4198 86 dev elo p e d a psycholo gic al theor y of the aetiology of suicide, sugg e s tin g that all suicides ten d to shar e co" " o n psychologic al feat ur e s 7f the s e , $hneid " a n reg a r d e d psychological pain or psychache as the single key co" " o n feat ur e +e #eliev e s that suicide is the hu" a n respo n s e to e&tr e " e psych ologic al pain, and that suicide prev e n tio n should focus on "e e ti n g the e"o tion al nee d s of suicidal individu als A secon d contri#ution has co"e fro" res e a r c h conduc t e d in psychia t ric epid e "iolog y !his res e a r c h has tend e d to e&plain suicide al"os t e&clusiv ely in ter " s of o#s erv e d associa tio n s #etw e e n a rang e of psycho #iological risk factors and suicidal #eh a viour In this resp e c t , suicide res e a r c h within the last few deca d e s has followed tren d s in psychia tric epid e "iolog y that hav e focus e d on the dev elo p " e n t of statistical "od els of risk and resiliency !hes e "od els hav e the cap acity to integr a t e a nu "# e r of differe n t theor e tic al constru c t s that span #iological, gen e tic, psycholo gic al, psychia tric and sociological factors A third line of res e a r c h that is likely to ass u " e an incre a sin g i"port a n c e in the e&plan a tio n of suicidal #eh a viour s has #ee n provid e d #y rece n t work in #eh a vio ur al gen e tics In particular, ther e is growing evide n c e fro" twin studie s to sugg e s t the gen e tic inherit a #ility of suicidal #eh a viour 4$tat h a " et al 19986 2ece n t studie s hav e identified a nu" # e r of gen e tic and #iological factors ass ocia t e d with suicidal #eh a vio ur s 4*ann et al 50016, and New Zeala n d res e a r c h has de " o n s t r a t e d a gen e) #y) environ " e n t inter a c tion 4.aspi et al 500:6 !his res e a r c h sugg e s t s that suicidal #eh a viour s are not si"ply a respo n s e to environ " e n t a l adv er sity, #ut reflect individu al and gen e tic ally det er "i n e d vulner a #ilities to thes e #eh a viour s A cont e " p o r a r y pers p e c tiv e on suicidal #eh a vio ur has co" e fro" the in%ury prev e n tio n field !his appro a c h is #as e d on the ass u " p ti o n that suicide can #e conce p t u a lis e d as a for" of inten tio n al in%ury
!aken toge t h e r , all of thes e consid er a tio n s point to the ne e d for a co"pr e h e n s iv e and over arc hin g theor y that has the cap a city to integr a t e gen e tic, individu al, social, econo "ic, psychia tric and psych ological factors into a #roa d e&pla n a t o r y "od el of the aetiology of suicidal #eh a vio ur s !he differe n t theor e tic al fra" e w o rk s that hav e #e e n dev elop e d to e&a "i n e and e&plain suicide hav e, in turn, led to the dev elo p " e n t of differe n t stra t e gi e s for suicide prev e n tio n $pecifically, sociological and "acro e c o n o "i c theorie s hav e led to an e"p h a s i s on popula tio n) level chan g e in the social, econo "ic and relat e d struct u r e s that are #eliev e d to foster the dev elo p " e n t of suicidal #eh a viour s In contr a s t, "e n t al he alth and psychia tric e&pla n a tio n s of suicide hav e ten d e d to focus on the #ett e r identification, tre a t " e n t and "a n a g e " e n t of psychia tric disord e r s as the pri"a r y rout e to suicide prev e n tio n @inally, in%ury prev e n tio n pers p e c tiv e s hav e ten d e d to focus on restricting acce s s to the "e a n s of suicide In addition to thes e differing disciplinary e"p h a s e s , ther e hav e #ee n de# a t e s a#ou t differe n t appro a c h e s to prev e n tio n !hes e de# a t e s hav e centr e d aroun d the e&t e n t to which prev e n tio n is #ett e r deliver e d via univers al, popula tion) level pu#lic health interv e n tio n s , or interv e n tio n s targ e t e d at high) risk popula tion s !he rece n t focus on a pu#lic he alth appro a c h to suicide prev e n tio n has largely #e e n "otiva t e d #y par allels draw n #etw e e n cardiov a s c ul a r dise a s e and suicide, pointing out that the prev e n tio n of cardiov a s c ul ar dise a s e #ec a " e succe s sf ul only when it "ov e d fro" a clinical focus on tre a tin g high) risk patie n t s who had alre a d y "a nife s t e d the dise a s e , to a popula tio n) #as e d appro a c h focusing on chan gin g knowled g e , attitu d e s , #eh a viour s and cultur al nor "s to prev e n t the dev elop " e n t of cardiov a s c ul a r dise a s e in the popula tion at large 43no& et al 500;6 !his appro a c h of shifting the entire popula tion distri#ution of risk is consist e n t with 2oses !heor e " that Aa large nu "# e r of people at s"all risk "ay give rise to "or e cas e s of dise a s e than a s"all nu "# e r at high risk 42ose 19956 It is argu e d that suicidal #eh a vio ur and cardiov a s c ul ar dise a s e hav e in co" " o n a "ultifactorial aetiology, and that suicide prev e n tio n would, like the prev e n tio n of cardiov a s c ul a r dise a s e , #en efit fro" populatio n) #as e d appro a c h e s ai"e d at chan gin g attitu d e s , nor" s and #eh a viour s which predis p o s e people to suicide and other adv er s e outco " e s with which suicide is linked 4eg, su#s t a n c e a#us e and violent, antisocial and offending #eh a viour s 6 It see " s likely that "os t countries hav e, or will dev elo p, nation al suicide prev e n tio n stra t e gi e s which are place d within a pu#lic healt h fra" e w o rk design e d to per "it a #roa d rang e of social, econo "ic, health, "e n t al health, cultur al and other risk factors to #e integr a t e d and targ e t e d 4Benkins and $ingh 5000? Benkins 5005? C$ ,epart " e n t of +ealth and +u"a n $ervice s 50016 @urth e r, curre n t political ideologie s app e a r to favour a pu#lic health fra" e w o rk for dev elo pin g and i"ple " e n ti n g the typ e s of policy chan g e s that are see n as nece s s a r y to gen e r a t e popula tion shifts of risk factors to
"ak e an i"pact sufficient to reduc e suicidal #eh a vio ur Inde e d, reduc tio n s in suicidal #eh a vio ur hav e #ee n prove n effectiv e at a popula tion level? for e&a " pl e , reducin g popula tio n acce s s to a particular "e a n s of suicide, coal gas, reduc e d #oth over all suicide rat e s and suicide rat e s #y that "e t h o d 43reit " a n and 0latt 198;6 Althoug h it app e a r s likely that pu#lic healt h appro a c h e s will do"in a t e the are a of suicide prev e n tio n, ther e is, non e t h el e s s , a cas e for "or e targ e t e d interv e n tio n s In particular, thos e individu als who "ak e suicide att e " p t s hav e e" e r g e d as an identifia#le high) risk popula tion that is char a c t e ris e d #y ongoing "e n t al he alth pro#le " s and high "ort ality 4/eau tr ais et al 5000? /eautr ais 500; a , 500; #6 0rag " a tic ally, popula tio n) #as e d progr a " " e s will nee d to #e supple " e n t e d #y "or e targ e t e d and inten siv e progr a " " e s for high) risk grou p s such as thos e "aking serious suicide att e " p t s In su " " a r y, the theorie s , appro a c h e s and findings of sociology, philosop h y, psycholo g y, "e dicin e, psychia t ric epide "i olo g y, pu#lic he alth, #eh a viour al gen e tics and in%ury prev e n tio n hav e all "a d e contri#ution s to our curre n t und er s t a n d i n g of suicide !his short historical overview provide s a #ackgro u n d to the "ultidisciplinar y appro a c h that is re=uire d to und e r s t a n d what we curre n tly know a#ou t the issue s , caus e s and risk factors for suicidal #eh a vio ur, and the pote n ti al points of effectiv e interv e n tio n to reduc e and prev e n t suicide +owev e r, the evide n c e supp ortin g the s e pers p e c tiv e s has #ee n varia#le, with "os t of the curre n t knowled g e a#ou t the caus e s and cons e = u e n c e s of suicidal #eh a vio ur co"ing fro" epide "i olo gic al res e a r c h conduc t e d over the last two dec a d e s !he cont e n t s of this review inevit a #ly reflect the e&t e n t and =uality of evide n c e fro" the s e differe n t pers p e c tiv e s
Scope
@or the purpos e s of this report, Asuicidal #eh a viour is define d as any act of self) in%ury und e r t a k e n with the inten t of har "in g ones elf +enc e this review is li"ited to consid er a tio n of 4co"pl e t e d 6 suicide, suicide att e " p t s that do not res ult in de a t h, and the #eh a viour s so" e ti " e s referr e d to as par a s uicid e and deli#er a t e self) har " 0aras uicid e is define d as Aall inten tio n al self) des tr uc tiv e #eh a viour s D as long as thes e #eh a vio ur s app a r e n tl y are inten d e d to #ring a#ou t chan g e s in the pres e n t situa tion throu g h the actu al or inten d e d har " or uncon s cio u s n e s s inflicted upon the #ody 4/ille) /rah e et al 199;6 ,eli#er a t e self) har " is define d as Aan act of inten tio n al self) poisoning or self) in%ury, irres p e c tiv e of the app a r e n t purpos e of the act 4/oyce et al 500:6 1&plicitly e&clud e d are high) risk) taking #eh a viour s 4eg, driving cars fast, s"oking6, wher e ther e "ay #e a tan g e n ti al risk of self) har " secon d a r y to other inten tion s $elf) "utilat ory #eh a viour s are also e&clud e d !he focus of the report is on suicide and suicide att e " p t , and 4gen e r ally6 suicidal idea tio n is not includ e d in the review if idea tion is addr e s s e d in the a#s e n c e of suicide or suicide att e " p t
"
!his report has not att e " p t e d to review all pu#lish e d studie s , #ut has focus e d on rece n t , relev a n t res e a r c h, which is 4su#s t a n ti ally6 that pu#lish e d in the 1nglish langu a g e after 1990
Structur e of the report

!his report has #e e n co" "is sio n e d #y the *inistry of +ealth to provide a litera t u r e review of the risk and prot ec tiv e factors and points of effectiv e interv e n tio n for suicide and suicide att e " p t acros s all age group s and popula tion s in New Zeala n d !he report is pres e n t e d in five parts 0art 1 looks at the epide "i olo g y and rece n t tren d s of suicide and att e " p t e d suicide in New Zeala n d 0art 5 the n looks at risk factors for suicide and att e " p t e d suicide, which is followed in 0art : #y a discus sion of resiliency and prot ec tiv e factors for suicide and att e " p t e d suicide 0art ; e&a "i n e s cultur al issue s consid er e d in the dev elo p " e n t and i"ple " e n t a t i o n of a cultur ally relev a n t suicide prev e n tio n strat e g y in New Zeala n d , and 0art 8 covers points of effectiv e interv e n tio n to reduc e and prev e n t suicide and att e " p t e d suicide !here is then a short final part 40art E6 drawing over all conclusions fro" the discus sio n
1 Time Trend s and $pide mi olo % &

!o provide #ackgro u n d and cont e & t for the litera t u r e review, this section e&a "i n e s the epide "i olo g y of suicidal #eh a viour s in New Zeala n d , including ti"e tren d s , gen d e r differe n c e s , age differe n c e s , eth nic differe n c e s , and popula tion s at incre a s e d risk of suicide and suicide att e " p t
Time trend s in 'ew (ealan d suicide rates, 1)#* **

$uicide rate s were relativ ely sta#le fro" 1980 to the "id) 1980 s , then incre a s e d fro" the "id) 1980 s to the late 1990 s 4see @igure 16 *ost rece n tly, suicide rate s hav e #egu n to decline fro" a 80) year peak of 1; : dea t h s per 100,0 0 0 in 1998 !he nation al suicide rate in 5005 4the "os t rece n t year for which dat a is availa#le6 was 10 9 per 100 000, repr e s e n ti n g a 58 perc e n t reduc tio n in five year s !his reduc tio n is par allele d #y si"ilar decr e a s e s in oth er countrie s 4eg, Australia6
+i%ure 1, 'e( )ealand age+ ad=usted sui4ide rates, %;50A2002
Deaths per 1**,*** %/
%,
%2
%0
0 %;50
%;55
%;/0
%;/5
%;-0
%;-5
%;.0
%;.5
%;;0
%;;5
2000
'ote: 2002 data are 8ro6isional.
In New Zeala n d suicide rate s for "ales show e d a relativ ely ste a d y incre a s e fro" 1980 to the "id) 1990 s , then #eg a n to decline 4se e @igure 56 !he "ale rate of suicide in 5005 was 1E E per 100,0 0 0 co"p a r e d to 1: : in 1980 !he incre a s e in rate s of "ale suicide is largely #ut not wholly e&plain e d #y a rapid incre a s e in rat e s of youth 4age s 18 5;6 suicide that occurr e d after
1990 In contr a s t , the rate for fe" al e s has re" ai n e d low and relatively sta#leF ; E in 1980 and 8 5 in 5005
+i%ure
25 Male ?e5ale 20
, 'e( )ealand sui4ide rates, "y se$, %;50 2002
Deaths per 1**,***
%5
%0
0 %;50
%;55
%;/0
%;/5
%;-0
%;-5
%;.0
%;.5
%;;0
%;;5
2000
'otes: 2002 data are 8ro6isionalF rates are annual age+ standardised rates.
2ate s of "ale youth suicide #eg a n to incre a s e in the 1990 s and the n show e d an a#ru p t incre a s e over the period fro" the "id) 1980 s to the "id) 1990 s +owev e r, since 1998 the "ale youth suicide rate has tend e d to decline 4se e @igure :6 !he rea s o n s for the rapid incre a s e in "ale youth suicide rat e s in the "id) 1980 s are not known It has #ee n sugg e s t e d that this incre a s e reflects the effects of econo "ic restruc t u rin g in New Zeala n d on the life opport u nitie s of youn g "ale s 4+ass all 19996 +owev er, this e&plan a tio n is not consist e n t with the facts that, at an individu al level, associa tio n s #etw e e n econo "ic factors and youth suicide rate s tend to #e relativ ely "od e s t 4/eau tr ais et al 1998c? /lakely 5005? @ergu s s o n et al 1999, 50016, and yout h suicide rat e s ros e in "a n y countries during this ti"e, with incre a s e s occurring in countries that did not und e r g o the econ o "ic restruc t u rin g e&p erie n c e d in New Zeala n d It is ther efor e unlikely that econo "ic restr uc t u rin g in itself is an ade = u a t e e&plan a tio n, and "or e likely that the rapid incre a s e in "ale yout h suicide o#s erv e d in New Zeala n d , and intern a tio n ally, was the net cons e = u e n c e of a nu" # e r of inter a c tin g factors 4including incre a sin g su#s t a n c e use, chan gin g fa"ily struct ur e s , rising interp e r s o n a l violenc e, and chan gin g econo "ic and social opport u nitie s 6, which co"#in e d to incre a s e vulner a #ility to suicide a"o n g youn g "ale s 42utt er and $"ith 19986
Annual nu" # e r s of fe" al e youth suicide s are low, so this dat a warra n t s cautious interpr e t a tio n +owev e r, fe" al e youth suicide rate s app e a r to #e incre a sin g at the sa " e ti"e that "ale youth rate s are declining In 1988 fe" al e s accou n t e d for 50 perc e n t of yout h suicide s 4age s 18 5;6? in 5005 :5 perc e n t of youth suicide s were fe"al e
+i%ure !, 'e( )ealand youth 0%5 2, years2 sui4ide rates, "y se$, %;50 2002
Deaths per 100,000 50 45 40 35 30 25 20 15 10 5 0 1950 1955 1960 1965 1970 Male 1975 1980 1985 1990 1995 2000
Fem ale
'ote: 2002 data are 8ro6isionalF rates are age standardised.
/end e r differe n c e s
*ales accou n t for thre e) =uart e r s of all suicide dea t h s in New Zeala n d In 5005 9E 1 perc e n t 4:80<; E 0 6 of suicide s were "ale !he rate of suicide for fe" al e s in 5005 was 8 5 per 100,0 0 0 4co"p a r e d with 1E E for "ale s6
A%e differe n c e s
1&a "in a tio n of age) specific suicide rate s show s that fro" 1980 to 5005 suicide rat e s incre a s e d a"o n g yout h 4age s 18 5;6 and youn g adults 4ag e s 58 ;;6 In contr a s t , suicide rat e s decr e a s e d a"o n g adults in their "iddle years 4age s ;8 E;6 and in older adults 4over ag e E;6 4see @igure ;6 A "or e co"pr e h e n s iv e e&a "in a tio n of age differe n c e s in suicidal #eh a vio ur s show s that, at pres e n t , suicide risk for "ale s ten d s to incre a s e up to age 50, re" ain relatively sta #l e over the period fro" 50 to :9 year s, decline to ag e E9, and incre a s e ther e a f t e r 4 see @igure 86 *ales age d 50 ;;
hav e the highe s t risk 2ate s of suicide a"o n g tee n a g e r s are less than half the rat e s of suicide a"o n g youn g adult "ale s 4age s 50 5;6 !hus it is i"port a n t to not e that "uc h of what ten d s to #e descri# e d as Ayouth suicide is in fact suicide involving young adult "ale s ag e d 50 5; rath e r tha n tee n a g e r s @or fe" al e s , suicide rat e s tend to incre a s e to age 5;, re" ai n relativ ely high to age ;8, and tend to decline ther e af t e r In contr a s t to "ale s, rate s of suicide a"o n g fe"al e s are si"ilar for tee n a g e r s 4age s 18 196 and for youn g adults 4ag e s 50 5;6
+i%ure ", 'e( )ealand age+ s8e4i i4 sui4ide rates, %;50 2002
&5 A%e1standardised rate 2per 1**,***3 %5A2, years 25A,, years ,5A/, years /5 years G
&0
25
20
%5
%0
0 %;50
%;55
%;/0
%;/5
%;-0
%;-5
%;.0
%;.5
%;;0
%;;5
2000
+i%ure #, Sui4ide rates, "y age and se$, 'e( )ealand, 2002
A%e1standardised rate 2per 1**,***3 ,0 Male ?e5ale &5
&0
25
20
%5
%0
0 %0A%, %5A%; 20A2, 25A2; &0A&, &5A&; ,0A,, ,5A,; 50A5, 55A5; /0A/, /5A/; -0A-, -5A-; .0A., A%e %roup 2&ears3 .5G
$uicide contri#ut e s to "ort ality differe n tly for differe n t ag e grou p s @or #oth "ale s and fe"al e s the perc e n t a g e of dea t h s attri#ut a #l e to suicide ten d s to incre a s e up to age s 50 5;, and the n decline s with incre a sin g ag e 4see @igure E6 After ag e E0 suicide accou n t s for an incons e = u e n t i al proportion of all de a t h s In contr a s t , suicide accou n t s for one) third of all "ort ality in "e n ag e d 50 :; In ter " s of contri#u tio n s to ag e) specific "ort ality rate s , suicide has its gre a t e s t i"pac t on "ale s age d 50 :9 years , rath e r than on tee n a g e r s or older adults, sugg e s ti n g that a "a%or focus of suicide prev e n tio n should #e on "e n in their 50s and :0s
1*
+i%ure -, Per4entage o total 5ortality a44ounted or "y sui4ide, "y age and se$, 200%
A%e1standardised rate 2per 1**,***3 &5 Male ?e5ale &0
25
20
%5
%0
0 %0A%, %5A%; 20A2, 25A2; &0A&, &5A&; ,0A,, ,5A,; 50A5, 55A5; /0A/, /5A/; -0A-, -5A-; .0A., A%e %roup 2&ears3 .5G
4a5or cause s of death

Anoth e r way of illustra tin g the e&t e n t of the pro#le " of suicide is #y e&a "i nin g the stat u s of suicide as a caus e of de a t h 4 see !a#le 16 In New Zeala n d , for the year 5000, suicide was the ninth leading caus e of dea t h over all, and rank e d a"o n g the 10 leading caus e s of dea t h for all New Zeala n d e r s e&ce p t adults age d E8 and over @or youth and youn g adults age d 18 :; years , suicide was the seco n d leading caus e of de a t h 4after accide n t s 6, and for adults age d :8 ;; suicide was the fourth leading caus e of dea t h 4after canc e r, hear t dise a s e and accid e n t s 6
Table 1,
6ankin % % 2 & , 5
'e( )ealand leading 4auses o death, "y age grou8, 2000

A%e %roup 2&ears3 1* 1" 1# " A44idents Sui4ide Can4er # !" A44idents Sui4ide Can4er !# "" Can4er !eart disease A44idents Sui4ide Endo4rine "# #" Can4er !eart disease A44idents Endo4rine ## -" Can4er !eart disease >es8iratory Endo4rine -#7 !eart disease Can4er >es8iratory Endo4rine 'er6ous syste5 Total !eart disease Can4er >es8iratory Endo4rine A44idents
A44idents Can4er Congenital 'er6ous syste5 Sui4ide
Hndeter5ine !eart d disease Congenital 'er6ous syste5
>es8iratory A44idents
11
/ . ; %0
Endo4rine >es8iratory *n e4tious diseases
!eart disease Assault Endo4rine
Congenital
>es8iratory Sui4ide 'er6ous syste5 Digesti6e syste5 *n e4tious diseases Congenital
Digesti6e syste5 'er6ous syste5 Sui4ide *n e4tious diseases
Digesti6e syste5 Mental disorders A44idents <enitourinary
'er6ous syste5 Digesti6e syste5 Mental disorders Sui4ide
Hndeter5ine 'er6ous d syste5 Endo4rine Assault *n e4tious diseases *n e4tious diseases Digesti6e syste5 Assault
Hndeter5ine 'er6ous d syste5 A >es8iratory
Mus4ulos1eleta Mus4ulos1eleta <enitourinar l l y
'otes: !eart disease: any disease o the 4ir4ulatory syste5, in4luding 4ere"ro6as4ular disease. Can4er: neo8las5s. *n e4tious diseases: any in e4tious98arasiti4 diseases. Endo4rine: endo4rine, nutritional and 5eta"oli4 diseases 0eg, dia"etes2. Mental disorders: any 5ental or "eha6ioural disorders, in4luding organi4 disorders. Congenital: 4ongenital 5al or5ations, de or5ations and 4hro5oso5al a"nor5alities. 'er6ous syste5: any disease o the ner6ous syste5 0eg, e8ile8sy, de5yelinating disorders, et42. A44idents: any death "y unintentional in=ury. Digesti6e syste5: any disease o the digesti6e syste5 0eg, li6er, intestines, et42. >es8iratory: any disease o the res8iratory syste5. Mus4ulos1eletal: any disease o the 5us4ulos1eletal syste5 and 4onne4ti6e tissue 0eg, "one diseases, et42. <enitourinary: any diseases o the genitourinary syste5 0eg, renal ailure, et42. Hndeter5ined: any e6ent o undeter5ined intent.
Suicide rate s b& ethnicit&

In New Zeala n d the det e r "i n a tio n of eth nicity of thos e dying #y suicide was chan g e d in 1998 4*inistry of +ealth 5001 #? $tatistics New Zeala n d 19986 Cntil 1998 eth nicity was #as e d on an ass e s s " e n t of the individu als e&t e n t of *ori desc e n t 2ecognition of the li"itation s of this "et h o d of "e a s u r e " e n t led to a revision of dat a collection "et h o d s $ince 1998 eth nicity has #e e n define d on the #asis of the fa"ilys report of the individu als eth nic self) identification !his chan g e in definitions led to a clear discontinuity in ti"e) series dat a, and recog nition that *ori suicide was likely to hav e #e e n und e r) enu " e r a t e d prior to 1998 @or #oth "ale s and fe"al e s , fro" 199E throu g h to 1998 *ori had high er rate s of suicide than non) *ori 4see @igure 96 , #ut since 1999 *ori rat e s hav e ten d e d to conver g e with thos e of non) *ori +owev er, in 5005 *ori "ale 419 9 per 100 0006 and fe"al e 48 96 rate s still re" ai n e d higher than non) *ori rate s 4"ale s 18 E? fe" al e s ; 86 @or *ori yout h, suicide tren d s differ fro" thos e for the total *ori population /oth young "ale and fe" al e *ori hav e had high er rate s of suicide tha n non) *ori each year fro" 199E to 5001 4see @igure 86 *ost rece n t dat a 450016 sugg e s t s that youn g *ori "ales 4;: 9 dea t h s per 100,0 0 0 6 and fe" al e s 418 86 hav e significantly high er rate s of suicide tha n their non) *ori pe ers 4"ale s 18 0? fe" al e s 9 16
+i%ure ., M ori and non+ M ori sui4ide rates, total 8o8ulation, "y se$, %;;/ 2002
&5 A%e1standardised rate 2per 1**,***3 MCori 5ale 'on+MCori 5ale MCori e5ale 'on+MCori e5ale
&0
25
20
%5
%0
0 %;;/
%;;-
%;;.
%;;;
2000
200%
2002
In 5005, 18 0acific people died #y suicide 41; "ales , four fe" al e s 6, and ther e were 15 de a t h s 410 "ale, two fe"al e6 of Asian peopl e
+i%ure 0, M ori and non+ M ori youth 0%5 2, years2 sui4ide rates, "y se$, %;;/A 200%
-0 A%e1standardised rate 2per 1**,***3 MCori 5ale 'on+MCori 5ale MCori e5ale 'on+MCori e5ale
/0
50
,0
&0
20
%0
0 %;;/
%;;-
%;;.
%;;;
2000
200%
1!
Intern a ti on al comp aris o n s of suicide rates

New Zeala n d suicide rate s are often co"p a r e d with rate s for a series of indus trialis e d, 71., countrie s 4see @igures 9 and 106 !he tot al "ale suicide rat e in New Zeala n d in 5005 41E E per 100 0006 was si"ilar to that of Australia 419 8 in 50016 #ut less tha n that of @inland 45E 8 in 50056 !he fe" al e suicide rat e for New Zeala n d 48 5 in 50056 was lower tha n the corres p o n di n g rate in @inland 48 1 in 50056 2ecen t intern a tio n al co"p a ris o n s of youth 4age d 18 5;6 suicide rat e s show that youn g "ales in New Zeala n d 455 8 per 100,0 0 0 in 50056 4NZ+I$ 500;6 rank e d third after @inland and Irelan d 4@igure 116 !he rat e was significantly high er tha n corre s p o n di n g rat e s in Australia, the Cnited $tat e s and the Cnited 3ingdo " 4'+76 5 !he suicide rat e for youn g fe" al e s in New Zeala n d 48 5 in 50056 was lower tha n for Bapan 48 8 in 50006, @ranc e 48 1 in 19996, @inland 48 1 in 50056, $wed e n 48 9 in 50016 and Norway 48 ; in 5001 4@igure 1566
+i%ure ), 3otal 5ale sui4ide rates or sele4ted #ECD 4ountries
?inland 020022 Ia8an 020002 ?ran4e 0%;;;2 *reland 020002 Australia 0200%2 'e( )ealand 020022 'or(ay 0200%2 Canada 020002 <er5any 0200%2 HSA 020002 S(eden 0200%2 'etherlands 020002 Hnited Bingdo5 0%;;;2 0 5 %0.2 ;.; %0 %5 20 25 &0 %..& %-.5 %/./ %5.%5./ %5.% %,./ %,.& 20.0 2/.5 25.&
A%e1standardised rate 2per 1**,***3
Sour4e: ')!*S. 'ote: Co58arison years 6ary "y 4ountry "et(een %;;. and 2002F 2002 data are 8ro6isional.
See htt8:99(((.(ho.int
1"
+i%ure 1*, 3otal e5ale sui4ide rates or sele4ted #ECD 4ountries

Ia8an 020002 ?ran4e 0%;;;2 ?inland 020022 S(eden 0200%2 'or(ay 0200%2 'e( )ealand 020022 'etherlands 020002 Australia 0200%2 Canada 020002 <er5any 0200%2 *reland 020002 HSA 020002 Hnited Bingdo5 0%;;;2 0 % 2 2./ & , 5 / . ; %0 &., &.. ,.,.5 ,.5 ,., 5., 5.2 5.; ..% ..% ...
+i%ure 11, Male youth sui4ide rates 0%5 2, years2 or sele4ted #ECD 4ountries
?inland 020022 *reland 020002 'e( )ealand 020022 'or(ay 0200%2 Australia 0200%2 Canada 020002 HSA 020002 Ia8an 020002 <er5any 0200%2 ?ran4e 0%;;;2 S(eden 0200%2 Hnited Bingdo5 0%;;;2 'etherlands 020002 0 5 ;., %0 %5 20 25 &0 %2., %2.& %%.2 %0./ %-.0 %5.. 20.20.2 22.. 22.% 25.& 2;.%
Sour4e: ')!*S.
1#
'ote: Co58arison years 6ary "y 4ountry "et(een %;;. and 2002F 2002 data are 8ro6isional.
+i%ure 1 , ?e5ale youth sui4ide rates 0%5 A2, years2 or sele4ted #ECD 4ountries
Ia8an 020002 ?ran4e 0%;;;2 ?inland 020022 S(eden 0200%2 'or(ay 0200%2 'e( )ealand 020022 'etherlands 020002 Australia 0200%2 Canada 020002 <er5any 0200%2 *reland 020002 HSA 020002 Hnited Bingdo5 0%;;;2 0 % 2 2./ & , 5 / . ; %0 &., &.. ,.,.5 ,.5 ,., 5., 5.2 5.; ..% ..% ...
1-
8ospitalisati on for suicide atte m p t

!he tot al popula tio n rat e of ad "is sion to hospit al for suicide att e " p t and self) inflicted in%ury for 5001<0 5 in New Zeala n d was 158 5 cas e s per 100,0 0 0 4@igure 1:6 2ate s of hospit alis a tion were twice as high for fe"al e s 41E9 : per 100,0 0 0 6 co"p a r e d to "ale s 48E 86 !hey were high e s t a"o n g youn g people age d 18 5; year s, with youn g fe"al e s 4ag e d 18 5; year s6 having the highe s t rat e s of hos pit alis a tio n 4;58 ;6 a"o n g all age and gend e r group s
+i%ure 1!, Sui4ide and sel + in li4ted in=ury hos8italisation rate, 200%902
A%e1standardised rate 2per 1**,***3 ,50 ,00 &50 &00 250 200 %50 %00 50 0 %0A%, %5A%; 20A2, 25A2; &0A&, &5A&; ,0A,, ,5A,; 50A5, 55A5; /0A/, /5A/; -0A-, -5A-; .0A., A%e %roup 2&ears3 .5G Male ?e5ale
1.
Trend s in meth o d s of suicide and suicide atte m p t

In 5005 the "os t co" " o n "et h o d s of suicide were hangin g 4;E 8 perc e n t of all suicides 6 and vehicle e&h a u s t gas 4#y car#o n "ono&id e poisonin g, 51 8 perc e n t 6, which toge t h e r accou n t e d for E8 perc e n t of all suicides 4se e @igure 1;6 ,uring the last two deca d e s ther e has #e e n a su#s t a n ti al incre a s e in dea t h s #y han gin g and #y vehicle e&h a u s t gas and a significant reduction in the use of firear " s 4/eau t r ais 1999 a 6 In 5005 firear " s accou n t e d for 10 9 perc e n t of all dea t h s @or #oth youn g "ale s and fe"al e s 4age d 18 5;6 hangin g has #eco " e incre a sin gly co" " o n , curre n tly 450056 accou n tin g for E; perc e n t of "ale and E0 perc e n t of fe" al e youth suicides !he do"in a n c e of hangin g, and the u#i=uitou s availa#ility of the "at e ri als and opport u nitie s for carrying it out, sugg e s t that ther e is li"ited pote n ti al to reduc e suicide s #y restricting acce s s to "e a n s of suicide 4/eau tr ais 5000 #6 !he clear policy i"plication of this o#s erv a tio n is that suicide prev e n tio n in New Zeala n d nee d s to focus on a rang e of appro a c h e s design e d to addr e s s the known risk factors for suicidal #eh a viour, rath e r tha n the i""e di a t el y pro&i" al issue of the "et h o d of suicide !he "et h o d s for suicide and suicide att e " p t differ 'hile "os t suicide s are accou n t e d for #y hangin g and vehicle e&h a u s t gas, "os t hospit alis a tion s 4over 80 perc e n t6 for att e " p t e d suicide are for self) poisonin g 4'eir and Ardag h 1998? /eau tr ais 199E? >i## and /eautr ais 500;6
+i%ure 1", Methods o sui4ide, "y gender, 2002
9 of total mortalit& 50 ,5 ,0 &5 &0 25 20 %5 %0 5 0 Poisoning C# !anging ?irear5s Dro(ning Iu58ing #ther Male ?e5ale
10
Population s at hi%h risk for suicide and suicide atte m p t

!here are sev er al populatio n s at high risk for suicide and suicide att e " p t , and the s e are discus s e d #elow :outh As we hav e see n, in New Zeala n d rat e s of "ale youth suicide #eg a n to incre a s e in the 1990 s and the n show e d an a#rup t incre a s e over the period fro" the "id) 1980 s to the "id) 1990 s 4*inistry of +ealth 5001 #6 ,uring this ti"e New Zeala n d "ale youth suicide rate s were a"o n g the high e s t in a series of co"p a r a #l e dev elo p e d 71., countrie s , which includ e d the C$A, C3, Australia, .ana d a , Bapan and @inland : .oncer n s a#ou t #oth New Zeala n ds high intern a tio n al ranking and the rapid incre a s e in youth suicide rate s led to a focus on yout h suicide prev e n tio n, which gen e r a t e d the dev elo p " e n t of the New Zeala n d Gouth $uicide 0rev e n tio n $trat e g y 4*inistry of Gouth Affairs et al 19986 $ince the "id) 1990 s the "ale yout h suicide rat e in New Zeala n d has halve d 4fro" a peak of ;; 1 in 1998 to 55 8 in 50056, althou g h it still "aint ain s a high intern a tio n al ranking *ore rece n tly, New Zeala n d fe" al e youth suicide rat e s hav e #egu n to incre a s e 411 per 100,0 0 0 in 50056 ; !hes e consid er a tio n s sugg e s t that youth re" ai n a high) risk grou p for suicide prev e n tio n 4 ori childre n and &outh In co" " o n with oth er tren d s in "ort ality in New Zeala n d 40 "ar e et al 1998? 0u#lic +ealth .entr e 19986, *ori youth are at higher risk for suicide tha n non) *ori youth 1sti" a t e s sugg e s t that in 5005 rate s of *ori yout h suicide were appro&i " a t e l y twice thos e of non) *ori, 8 for #oth "ale s and fe" al e s Accordingly, *ori children, adoles c e n t s and youn g people accou n t for a dispro p or tion a t e l y high fraction 4:8 perc e n t in 50056 of suicide s in thos e ag e d und e r 58 years 4/eau tr ais 500 1a6 !he rea s o n s for the high er rate of suicide a"o n g youn g *ori are not clearly und e r s t o o d , #ut it has #ee n sugg e s t e d that it "a y #e due to social and cultur al ine=u alitie s that "ak e *ori particularly vulner a #l e to suicidal #eh a vio ur s 4and to other poo r healt h outco " e s 6 4/lakely 5005? ,urie 5001 #6 Childre n who receiv e welfar e care New Zeala n d studie s hav e identified children and child welfare service s as a popula tion that has an and suicide att e " p t co"p a r e d with peer s who do 4$"ith and /eau tr ais 19996 'hat is "or e, *ori repr e s e n t e d in the welfare popula tion It is likely
& , 5
adoles c e n t s who receiv e elev a t e d risk of suicide not receive such service s youn g people are over) that the higher risk in this
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popula tion results fro" their e&po s u r e to disadv a n t a g e d , dysfunc tio n al and adv er s e childhoo d environ " e n t s !his adv er sity gives rise #oth to su#s e = u e n t suicidal #eh a viour 4/eau t r ais 1999 #? @ergus s o n et al 50006 and to the pro#le " s that accou n t for their nee d for welfar e service s A nation al progr a " " e to "onitor and provid e cas e "a n a g e " e n t for suicidal and at) risk young peopl e within the nation al .hildre n, Goung 0erson s and their @a"ilies $ervice 4.G0@6 has #ee n dev elo p e d 4.hild, Gouth and @a"ily 50086 ;lder adults $uicide res e a r c h and prev e n tio n efforts in New Zeala n d hav e previously focus e d on youth +owev er, the progr e s siv e ageing of the popula tio n sugg e s t s that #oth a#s olut e nu" # e r s and rat e s of suicide a"o n g older adults can #e e&p e c t e d to incre a s e @indings fro" #oth New Zeala n d res e a r c h 4/eau t r ais 5005, 500;c6 and intern a tio n al studie s 4+arwood and Baco#y 5000? 'aern et al 50056 sugg e s t that a"o n g older adults serious suicidal #eh a viour is attri#u t a #l e , in large part, to "a%or depr e s sio n !his o#s erv a tio n i"plies a very stron g focus for suicide prev e n tio n on the i"prov e d identification, tre a t " e n t and "a n a g e " e n t of depr e s sio n, and #ett e r recog nition of the physic al health, life eve n t, social, fa"ily and relat e d factors that "ay contri#u t e to the dev elop " e n t of depr e s sio n in this popula tion !his clear, single focus for older adult suicide prev e n tio n contr a s t s with the appro a c h nee d e d to addr e s s suicide prev e n tio n in young people, wher e the "ulti) factorial natur e of risk sugg e s t s a "ulti) co"p a r t " e n t a l appro a c h to prev e n tio n activities 4/eau tr ais 500: a6 $uicide att e " p t s are "or e leth al in older adults for sever al reas o n s F the elderly are physically "or e frail and less likely to survive the physic al se= u el a e of a suicide att e " p t ? they are "or e likely to live alon e and ther efor e to #e not found in ti"e for life) saving assist a n c e to #e given? they ten d to choos e "or e leth al "et h o d s of suicide, which "ay reflect a stron g e r inten t to die? and they ten d to "ak e suicide att e " p t s that are "ore carefully plann e d and i"ple " e n t e d 1fforts to dev elo p suicide prev e n tio n appro a c h e s for older adults nee d to take into accou n t a series of #arriers to interv e ni n g with this popula tio n !hes e #arriers includ e, for e&a " pl e , Aageis ", with suicide in older peopl e "or e likely to #e reg ar d e d as a ration al and und er s t a n d a # l e decision #y the gen e r al pu#lic, while yout h suicide is see n as "or e tragic and "or e des e rvin g of prev e n tio n !his view i"plies that ther e "a y #e less pu#lic and political suppor t for suicide prev e n tio n a"o n g older adults !his sugg e s t s that a co"pr e h e n s iv e appro a c h to suicide prev e n tio n a"o n g older adults ne e d s to includ e educ a tio n of the pu#lic and healt h care provid er s a#ou t feat ur e s of health y ag ein g, signs and sy"p t o " s of depr e s sio n, and co" " u ni t y and he alth care provision of supp ortiv e care Thos e who have mad e suicide atte m p t s Individu als who "ak e non) fatal suicide att e " p t s are at high risk of "ort ality fro" suicide and other caus e s 4/eau t r ais 500; #? 7sta " o and -onn=vis t
5001? >i## et al 5008? 7wens et al 5005? +awton et al 500:? +awton and @agg 1988? Zahl and +awto n 500;6 @or e&a " pl e , a New Zeala n d study followe d up :05 individu als who had "a d e "e dic ally serious suicide att e " p t s , and found that within five years 1 in 11 49 perc e n t6 had died *ost de a t h s 4E0 perc e n t6 were #y suicide 4/ea u tr ais 500; #6, #ut ther e were also e&c e s s dea t h s fro" "otor vehicle accid e n t s Anoth er stud y of all individu als who were ad "itt e d to .hristch urc h +ospital for a suicide att e " p t of any type of sev erity found that within 10 year s 1 in 50 had died #y suicide 4>i## et al su# "itt e d 6 !hes e findings are consist e n t with thos e fro" intern a tio n al studie s A rece n t syst e " a t ic review of 5E studie s found that thos e who "ak e suicide att e " p t s hav e a 0 8 to 5 perc e n t risk of suicide within one year of their att e " p t , and a suicide risk in e&ce s s of 8 perc e n t after nine years 47wens et al 50056 In addition to elev a t e d "ort ality rat e s , thos e who "ak e non) fatal suicide att e " p t s hav e high rate s of furth er suicide att e " p t #eh a vio ur 4/eau t r ais et al 500; a? >i## et al 5008? >airin et al 500:? 'ang et al 19886 A study of patie n t s ad "itt e d to .hristch urc h +ospital after a suicide att e " p t found that within 10 years al"os t one in thre e 458 perc e n t6 had "a d e at leas t one furth e r suicide att e " p t 4>i## et al 50086 A furth er study found that a"o n g thos e who "a d e a "e dic ally serious suicide att e " p t :9 perc e n t "a d e at leas t one furth er att e " p t in the following five year s 4/eau t r ais 500; a 6 In addition to high er rate s of su#s e = u e n t "ort ality and suicide att e " p t #eh a vio ur, thos e who "ak e suicide att e " p t s hav e significantly and consist e n tly higher rat e s of psychia tric "or#idity and an eleva t e d risk of a rang e of poor psych o s o ci al outco " e s after an inde& suicide att e " p t 4/eau tr ais et al 50006 In a .ant er # u r y stud y, for e&a " pl e, within :0 "ont h s of a "e dic ally serious suicide att e " p t , al"os t half 4;; perc e n t6 had #ee n ad "itt e d to a psychia tric hospit al, ;0 perc e n t of the sa " pl e "e t criteria for a su#s t a n c e ) a#us e disord e r, ;E perc e n t "e t criteria for depr e s sio n, al"os t E0 perc e n t report e d relation s hip pro#le " s , :0 perc e n t faced legal charg e s , 9 perc e n t had at leas t one ter " of i"prison " e n t , and al"os t thre e) =uart e r s 49: perc e n t 6 were social welfar e #en eficiarie s at the ti"e of at leas t one of the thre e follow) up interview s !hes e findings sugg e s t that thos e who are ad "it t e d to hospit al following a suicide att e " p t are a populatio n at high and enduring risk for furth er suicidal #eh a viour and poor outco " e s !hey are a relatively readily identifia#le group who re=uire short) ter " crisis interv e n tio n s and long er) ter " surveillanc e and "a n a g e " e n t Thos e in custod & and incarc e r a t e d A series of report s has sugg e s t e d that rate s of suicide and suicide att e " p t are higher in individu als who are in custo d y or incarc er a t e d 4in prison s, %ails and police cells6 than in the gen e r al popula tio n 4/onn er 1995? +aye s and 2owan 1988? 3erkhof and /erna s c o 1990? 'illia"s and *organ 199;6 In New Zeala n d , *ori are over) repr e s e n t e d in prison popula tion s , altho u g h a"o n g prison e r s the risk of suicide is si"ilar for *ori and non) *ori 4$keg g
and .o& 199:6 Individu als who die #y suicide in custo d y or prison tend to #e char a c t e ris e d #y a history of psychia t ric disord e r, including, particularly, depr e s siv e sy"p t o " s , su#s t a n c e a#us e , antisocial #eh a vio ur s and previou s suicide att e " p t s +owev er, "e n t al disord e r, prior suicide att e " p t s and su#s t a n c e a#u s e occur co" " o nl y in prison e r s , "aking identification of thos e at risk of suicide in incarc er a t e d populatio n s difficult 2ece n t cas e control studie s of suicidal #eh a vio ur in prison and<or custo d y hav e refine d the char a c t e ris tics, circu " s t a n c e s and factors that disting uis h #etw e e n prison e r s who att e " p t suicide or die #y suicide and thos e who do not !hes e factors includ e a history of suicidality, psych o tic diagno sis, psych o tr o pic "e dic a tio n, a highly violent inde& offenc e, and single) cell housin g 4@ruehw ald et al 500;6 !hes e findings sugg e s t ther e is a nee d to e&a "i n e how serious psychia tric "or#idity, including suicidal #eh a viour, is tre a t e d and "a n a g e d within the prison popula tio n In addition, the het er o g e n e i t y of the prison popula tio n and the difficulties this i"pos e s in det e r "i nin g risk factors for specific group s within this popula tio n hav e #ee n recog nis e d 4+aycock 199:? *orrison 199E6, and i"ply the nee d for furth er res e a r c h to deline a t e specific risk profiles for particular cate g o ri e s of individu als i"prison e d and confine d in police custo d y Thos e who are %a&, lesbian or bisex u al ,uring the last few years a nu "# e r of studie s of youn g adults and "iddle) age d "ales hav e show n that se&u al orient a tio n is a risk factor for suicidal #eh a vio ur, and that rate s of suicidal idea tio n and suicide att e " p t are elev a t e d a"o n g thos e who are gay, les#ian and #ise& u al 4 see, for e&a " pl e , /agley and !re"#l a y 1999? @ergus s o n et al 1999? +errell et al 1999 ? and for a review, *c,aniel et al 50016 !hes e studie s hav e unifor "ly report e d incre a s e d risks of suicide att e " p t and suicidal inten t a"o n g thos e who are gay, les#ia n and #ise&u al, with risk ratios rangin g fro" : E to 1: 9 4/agley and !re"#l a y 19996 A New Zeala n d stud y #y @ergus s o n and collea g u e s 4@ergu s s o n et al 19996 found that, in addition to a si&) fold incre a s e d risk of suicidal #eh a viour, thos e who were gay, les#ia n or #ise&u al also had high er risk of "ood disord e r s , su#s t a n c e ) use disord e r s and an&iet y disord e r s In contr a s t , incre a s e d risk of completed suicide in this popula tion has not #ee n de " o n s t r a t e d 42ich et al 198E, 1988? $haffer et al 19986 !he failure to find links with suicide "a y #e due to the fact that ass e s sin g se&u al orient a tio n following suicide is "ore difficult than ascer t ainin g se&u al orient a tio n a"o n g thos e "aking suicide att e " p t s , who can #e pers o n ally interview e d Althoug h the e" e r g e n t res e a r c h sugg e s t s clear links #etw e e n se&u al orient a tio n and suicide att e " p t risk, studies in this are a hav e tradition ally faced difficulties, centring aroun d the stud y of relatively s"all grou p s of gay and les#ian youth and issue s relating to the accur a c y of asc er t ai nin g gay, les#ia n and #ise&u al orient a tio n As a cons e = u e n c e ther e is a stron g ne e d to dev elo p a series of well) design e d studie s of large sa " pl e s to replicat e , e&t e n d and validat e the evide n c e review e d a#ov e
Thos e who are sociall& isolate d or exclud e d $ever al studie s hav e report e d that social factors including social isolation, living alon e, having fewer friends , Arootles s n e s s and a perc eiv e d lack of social suppor t are risk factors for suicidal #eh a vio ur 4Apple# y, .oop er, et al 1999? +eikkine n, Iso" e t s a , *arttu n e n , et al 1998? 0hillips et al 50056 *ore gen e r ally, a nu "# e r of studie s hav e report e d that individu als who lead socially isolat e d lives are "or e vulner a #l e to suicide than thos e peopl e with stron g fa"ily affiliations and social suppor t within the co" " u ni t y 4+eikkine n et al 199:, 199;? 3reit" a n 1999? *agn e) Ingvar et al 1995? *aris 19E9? !rout 19806 +owev e r, poor social suppor t "ay #e char a c t e ris tic of thos e individu als who are vulner a #l e to suicide att e " p t #ec a u s e of their life cours e, rath e r than their #eing predis po s e d to suicide risk #ec a u s e of their lack of social supp ort per se 4/eau tr ais 5001 #6 !hes e findings are suppor t e d #y a rece n t analysis #y 3endler 419996, who sugg e s t s that individu als "ay, to so" e e&t e n t , gen e r a t e their own social environ " e n t s , which "ay reflect individu al te " p e r a " e n t and gen e tic predis p o sition to "e n t al illness $ocial suppor t should not #e reg ar d e d as an environ " e n t a lly cre a t e d "e a s u r e in isolation fro" individu al te " p e r a " e n t and oth er pers o n al char a c t e ris tics @or "ales , alcohol a#u s e and alcoholis " are likely to #e i"port a n t factors relat e d to living alon e and to interp e r s o n a l loss es , providing a furth er reas o n for addr e s si n g su#s t a n c e a#us e pro#le " s in "ales in efforts to prev e n t suicide 4+eikkine n, Iso" e t s a , *arttu n e n , et al 19986
6isk +actor s
In rece n t year s intern a tio n al conc er n s a#ou t the pro#le " of suicide hav e led to a dra " a tic incre a s e in the volu" e of res e a r c h a#ou t the caus e s and risk factors for suicidal #eh a viour !here is now a large volu " e of infor" a tio n fro" psychia tric, epide "i olo gic al, gen e tic and #iological res e a r c h that gives a gen e r ally coher e n t and consist e n t pictur e a#ou t the risk factors for suicidal #eh a viour !his section e&a "in e s risk factors for suicide and suicide att e " p t s !o provid e a fra" e w o rk for und e r s t a n di n g the s e factors they are group e d into do" ai n s of conce p t u ally si"ilar factors
4ental disord e r s
*ent al disord e r s 4in particular, "ood disord e r s , su#s t a n c e ) use disord e r s and antisocial #eh a viour s 6 play the stron g e s t role in the aetiology of suicidal #eh a vio ur 0sychological auto p s y studie s using yout h, adult, all)ag e s , "ale and fe"al e sa " pl e s hav e invaria #ly show n high rate s of "e n t al disord e r a"o n g thos e dying #y suicide or "aking serious suicide att e " p t s 4 for review s, see .avan a g h et al 500:? -onn=vist 50006, ranging fro" 81 perc e n t to 100 perc e n t 4"e di a n , 9: perc e n t 6 4-onn=vis t 50006 !he appro&i " a t e l y 10 perc e n t of individu als who die #y suicide withou t an a&is I 41rnst et al 500;6 diagn o sis app e a r to hav e su#) thres h old psycho p a t h ol o g y, and are "or e si"ilar to thos e who die #y suicide with an a&is I "e n t al diagn o sis than a control grou p In controlled studies the prev al e n c e of "e n t al disord e r in thos e dying #y suicide or "aking serious suicide att e " p t s rang e s fro" E: to 98 perc e n t 4Apple# y, .oop er, et al 1999? 0hillips et al 5005? /eau tr ais 5001 #? @oster et al 1999? *olnar, /erk" a n , et al 5001? /eautr ais, Boyce, *ulder, et al 199E? -esag e et al 199;? .ava n a g h et al 1999 a , 1999 #? .heng 1998? $wahn and 0ott er 5001? 3essler et al 1999? Hi%ayaku " a r and 2a%ku " a r 19996 7dds ratios rang e fro" 1 8 to :8 4*olnar, /erk" a n , et al 5001? /eautr ais, Boyce, *ulder, et al 199E6 4ood disord e r s *ood disord e r s 4including "a%or depr e s sio n, #ipolar disord e r and dyst h y "i a 6 are the "e n t al disord e r s "os t co" " o nl y associat e d with suicide and serious suicide att e " p t /etw e e n 58 and 90 perc e n t of thos e who die #y suicide or "ak e serious suicide att e " p t s hav e a "oo d disord e r 4-onn=vis t 50006, with "os t studie s reporting stron g and significan tly incre a s e d risks, with odds ratio 4726 esti" a t e s rangin g fro" 11 to ;1 4/ea u tr ais , Boyce, *ulder, et al 199E? *olnar, /uka, et al 50016 !he risk of suicide is incre a s e d 50) fold for thos e with "a%or depr e s sio n, 18) fold for thos e with #ipolar disord e r, and 15) fold for dysth y "ic individu als 4+arris and /arraclou g h 19996 !he lifeti" e risk of suicide for thos e with "oo d disord e r is esti " a t e d at ; perc e n t 4Institut e of *edicine 50056
"
!he risk of suicide att e " p t or suicide dep e n d s on the severity of the depr e s siv e disord e r $uicidal ideation occurs in "ore than half of thos e with depr e s sio n, and suicidal idea s, plans and att e " p t s incre a s e with the incre a sin g sev erity of depr e s sio n !he su#%ectiv e 4rath e r than o#%ectiv e6 sev erity of curre n t depr e s sio n, toge t h e r with higher levels of suicidal idea tio n and fewer reas o n s for living, has #ee n shown to distinguis h psychia tric ally ad "it t e d patie n t s who "a d e suicide att e " p t s fro" thos e who did not 4*ann et al 19996 !he risk of suicide is incre a s e d in thos e with recurr e n t and<or chronic, co"p a r e d to single) episod e , depr e s sio n 4/eau t r ais 5005? 'aern et al 5005? >oodwin and Ba"ison 19906 As note d a#ov e, the risk of suicide is incre a s e d 18) fold in peopl e with #ipolar disord e r 4+arris and /arraclou g h 19996 @ro" 58 to 80 perc e n t of thos e with #ipolar disord e r "ak e at leas t one suicide att e " p t 4>oodwin and Ba"ison 19906, and the risk of suicide incre a s e s with incre a sin g sev erity of the illness 4+agn ell et al 19816, and app e a r s to #e high er in the first five years after diagn o sis 4'eek e 1999? >uIe and 2o#ins 19906 !he risk of suicide for fe" al e s and "ale s with #ipolar disord e r is si"ilar 4'eek e 19996, in contr a s t to the high er "ale risk for the gen e r al popula tion !he centr al role of "e n t al disord e r s , and not a #ly depr e s sio n, in the aetiology of suicide has #ee n clearly articulat e d in a rece n t co" " e n t #y Isacss o n and 2ich 4500:6 on issu e s of caus ality and tre a t " e n t in this fieldF !here is no argu " e n t ag ain s t suicide repr e s e n ti n g a co"pl e& set of varia#le s A fund a " e n t a l discov er y was "a d e in the late 1980 s 42o#ins et al 19896F the "a%ority of suicides were co" "it t e d #y people with clinical depr e s sio n !his finding has #ee n replicat e d over and over again and we #eliev e that "a n y, like us, hav e conclud e d that this conn e c tion has #ee n replicat e d enou g h to #e prov e n 'e hav e also pres e n t e d evide n c e that suicides occur infre=u e n tl y in people with depr e s sio n taking antid e p r e s s a n t "e dic a tion 4Isacs s o n et al 199;6 !hus, in spite of the Ae&tr e " e co"ple &ity of the phe n o " e n o n of suicide, a si"ple and test a #l e hypot h e si s can #e stat e d F depr e s sio n is a nec e s s a r y caus e of "os t suicide s /as ed on this propo sition, it has #ee n sugg e s t e d that effective suicide prev e n tio n "us t focus on i"proving identification and tre a t " e n t of depr e s sio n in the popula tio n 4Isacs s o n 50006 'hen we look at the declining suicide rat e s over the pas t dec a d e or so, we see a gre a t deal of supp ort for that theory Subs t a n c e 1 use disord e r s $u#s t a n c e ) use disord e r s 4including alcohol, cann a #is and other drug a#u s e and dep e n d e n c y6 are linked with suicidal #eh a vio ur, with psycholo gic al auto p s y studie s sugg e s ti n g that #etw e e n 19 and E: perc e n t of thos e dying #y suicide hav e a su#s t a n c e ) use disord e r, and controlled studies gen e r a tin g 72 esti" a t e s rangin g fro" 5 5 to 8 8 4*olnar, /erk" a n , et al 5001? *urphy 5000? .onner and .hiap ella 500;6 $u#st a n c e ) use disord e r s fre=u e n tly occur co"or #idly, often with depr e s sio n and<or an&iet y or antisocial disord e r s 4*urphy 50006 .o"or#idity is associa t e d with incre a s e d suicide
risk 4-onn=vist 5000? /eautr ais, Boyce, *ulder, et al 199E? 3essler et al 19996 *ore specifically, esti" a t e s sugg e s t that the risk of suicide is incre a s e d si&) fold for thos e with alcohol) use disord e r s 4+arris and /arraclou g h 19996 !he disinhi#iting and facilitatin g effects of acut e alcohol into&ica tion incre a s e the likelihood of i"pulsive and aggr e s siv e suicide att e " p t s 0opulation studie s sugg e s t that high nation al rate s of alcohol cons u " p ti o n and low "ini"u " legal drinking age are relat e d to incre a s e d suicide risk 4'ass e r " a n et al 1998? /irck" a y e r and +e" e n w a y 19996 2isk factors for suicide and suicide att e " p t in alcoholics tend to #e the sa " e as thos e for gen e r al populatio n sa " pl e s of suicides and "e dic ally serious suicide att e " p t e r s 4.onn e r et al 500:6, i"plying that suicide prev e n tio n in alcoholics "us t includ e a focus on depr e s sio n as well as su#s t a n c e a#us e $u#s t a n c e ) use disord e r s 4pre do "i n a n tl y alcoholis "6, altho u g h less co" " o n in older than youn g e r suicide victi"s, nev er t h el e s s plac e older adults at incre a s e d risk of suicidal #eh a vio ur 4'aern et al 5005? .lark and .lark 199:? +enrikss o n et al 1998? 'aern 500:6 1sti" a t e s sugg e s t that #etw e e n one) =uart e r to one) third of older adult suicide victi"s hav e a su#s t a n c e ) us e disord e r Anxiet& disord e r s An&iety disord e r s are found in : to 19 perc e n t of thos e with serious suicidal #eh a vio ur +owev e r, thes e are likely to #e lower) li"it esti " a t e s of an&iet y disord e r s , since "a n y studie s hav e failed to ask e&t e n siv ely a#ou t an&iet y disord e r s 4*olnar, /erk" a n , et al 5001? 3han et al 50056 An&iety disord e r s often occur co"or #idly with "oo d disord e r s and su#s t a n c e ) use disord e r s In so" e studie s , when the associa tio n #etw e e n an&iet y disord e r s and suicide is controlled for "oo d disord e r, an&iet y disord e r s do not "ak e a significant contri#u tio n to suicide, sugg e s ti n g that the o#s erv e d ass ocia tion #etw e e n an&iet y disord e r s and suicide "a y reflect "oo d disord e r s that are fre=u e n tly co"or #id with an&iet y disord e r s 4 see, for e&a " pl e , /eautr ais 1998 a 6 @indings fro" one series of studie s sugg e s t that an&iet y disord e r s in older adults with suicidal #eh a viour ten d to occur seco n d a r y to "oo d disord e r s and do not "ak e an inde p e n d e n t contri#u tio n to suicide risk 4'aern et al 5005? Allguland e r and -avori 199:6 0anic disord e r is associa t e d with a 50) fold incre a s e in risk of suicide att e " p t 4'eiss " a n et al 19896, and it has #ee n esti" a t e d that 50 perc e n t of thos e who die #y suicide hav e this disord e r 4$ch "id t et al 50006 0anic disord e r that is co"or #id with oth er "e n t al disord e r s is ass ocia t e d with higher suicide risk tha n panic disord e r alon e 4$ch "id t et al 5000? 'arsh a w et al 50006 It often occurs co"or #idly with depr e s sio n, and it "a y #e that depr e s sio n dev elo p s as a respo n s e to panic disord e r 4$ch "idt et al 50006 !he risk of "aking a plan for suicide, "aking a suicide att e " p t , and "aking an impulsive suicide att e " p t are incre a s e d for individu als with 0ost
!rau " a tic $tres s ,isord e r 40!$,6 4*olnar, /erk" a n et al 5001? 3essler et al 1999? 3essler 50006 0!$, usu ally occurs co"or #idly with depr e s sio n, alcohol and drug a#us e , and other an&iet y disord e r s 43essler 19986 Schi<oph r e ni a .ontrolled studies of suicide and att e " p t e d suicide sugg e s t that #etw e e n E and 19 perc e n t 4"e di a n 8 perc e n t6 of thos e with such #eh a viour hav e schiIophr e ni a 42ado " s k y et al 1999? 0o"pili et al 500;6 'hile schiIophr e ni a occurs infre=u e n tl y 4esti " a t e d at 1 perc e n t6 in the gen e r al popula tion, and "ay not "ak e a large contri#ution to total populatio n rate s of suicide, a"o n g the popula tion of thos e with schiIophr e ni a the lifeti" e risk of suicide is esti " a t e d to #e ; to 10 perc e n t 4!sua n g et al 19956, and the suicide risk is :0 ;0 ti"e s high er tha n the risk in the gen e r al popula tion 4+arris and /arraclou g h 19996 /etw e e n 58 and 80 perc e n t of all thos e with schiIophr e ni a will "ak e a suicide att e " p t !he risk factors for suicide in thos e with schiIophr e ni a includ e a previou s suicide att e " p t ? significan t depr e s siv e sy"p t o " s ? hop el e s s n e s s ? alcohol or other su#s t a n c e a#u s e ? "ale gend e r? co" " a n d hallucina tio n s ? poor work and social functioning? social isolation? #eing un" a r rie d? rece n t loss or re%ection? a poor =uality of life? and a det erior a tin g illnes s cours e in thos e with high pre " o r #i d perfor " a n c e 4*orte n s e n et al 5000? 3aplan and +arrow 199E? ,e +ert et al 5001? *eltIer and 7kayli 19986 $atin% disord e r s In a study of fe"al e s with eatin g disord e r s , one in four had a history of suicide att e " p t , a rat e four ti"e s high er tha n that for the gen e r al fe" al e popula tion Also, one in four report e d curre n t suicidal idea tio n 4*ilos et al 500;6 In thes e people, suicidal idea tion and risk of suicide att e " p t were associa t e d with incre a sin g co"or #idity .o" " o n co"or #id disord e r s includ e d "oo d and clust e r / 4antisocial, #ord e rlin e, histrionic and narcissistic6 pers o n ality disord e r s Perso n a lit& disord e r s and traits 0erson ality disord e r s are associa t e d with incre a s e d risk of suicide and suicide att e " p t , indep e n d e n t l y and co"or #idly with a&is I disord e r s 4/aud 5008? Gen et al 500;? *ehlu " 5001? Iso"e t s a et al 199E6 !he lifeti"e risk of suicide for thos e with pers o n ality disord e r s has #ee n esti" a t e d at ; to 8 perc e n t 4@oster et al 1999? Iso"e t s a et al 199E? -ineh a n et al 5000? +enrikss o n et al 199:6 0erson ality disord e r s tend to occur co"or #idly with at leas t one a&is I diagn o sis, co" " o nl y depr e s sio n and<or su#s t a n c e ) use disord e r 4Iso" e t s a et al 199E6 !he pers o n ality disord e r s "os t co" " o nl y associa t e d with suicide are antisocial pers o n ality disord e r and #ord erline pers o n ality disord e r 4for review s, see /aud 5008? -ineh a n et al 50006 /orderline pers o n ality disord e r is linked with incre a s e d risk of suicide
att e " p t and suicide, eve n when the self) in%ury criterion is e&clud e d 4Gen et al 500;? Gen and $iegler 500:? /rodsky et al 19996 +istories of a#us e are co" " o n in thos e with #ord erline pers o n ality disord e r 4/rodsky et al 19996, and childhoo d se&u al a#u s e is a posite d caus a tiv e factor for #ord erline pers o n ality disord e r 4>und e r s o n and $a#o 199:? 0aris 19986 $ignifican t associa tio n s hav e #ee n report e d #etw e e n "e a s u r e s of antisocial #eh a viour, including adult antisocial #eh a vio ur and antisocial pers o n ality disord e r, and suicide 4/eau t r ais 5001 #? 3essler et al 1999? -ineh a n et al 50006 @re=u e n tly, antisocial #eh a vio ur s occur co"or #idly with depr e s sio n and su#s t a n c e ) use disord e r s 4/eau t r ais 5001 #? /eautr ais, Boyce, *ulder, et al 199E? 3essler et al 19996
4ental health factors

In addition to the "e n t al disord e r s ass ocia t e d with suicide and suicide att e " p t , ther e are a series of relat e d factors that are linked to risk of suicide and suicide att e " p t !hes e factors are discus s e d #elow Comor bi dit& +igh rat e s of co"or #idity 4co) occurr e n c e of two or "or e "e n t al disord e r s 6 are found a"o n g thos e "aking suicide att e " p t s or dying #y suicide, with co"or #idity co" " o nly occurring #etw e e n "oo d and su#s t a n c e ) us e disord e r s , and, in "ale s, #etw e e n depr e s sio n, su#s t a n c e ) use disord e r s and antisocial #eh a viour 4-onn=vist 5000? /eautr ais, Boyce, *ulder, et al 199E? -esag e et al 199;? .heng 1998? 3essler et al 19996 *ore than half of thos e dying #y suicide or "aking serious suicide att e " p t s hav e co"or #id disord e r s 4/eau tr ais, Boyce, *ulder, et al 199E? 3essler et al 19996 !he risk of suicidal #eh a viour incre a s e s e&pon e n ti ally with incre a s e d nu" # e r of co"or #id "e n t al disord e r s 4/eau t r ais , Boyce, *ulder, et al 199E6 $uicide risk is also incre a s e d in thos e with co"or #id "e n t al disord e r s and so" a tic disord e r s 4-onn=vis t 50006, and 4as not e d a#ov e6 in thos e with co"or #id a&is I disord e r s and pers o n ality disord e r s 4/aud 50086 Previous suicidal beh a vio ur 0rior suicide att e " p t s predict futur e suicidal #eh a viour A significan t proportion 4#etw e e n 19 and E8 perc e n t , "e di a n 58 perc e n t 6 of thos e who die #y suicide hav e "a d e previou s suicide att e " p t s , with 72 esti " a t e s ranging fro" : E to :1 9 4"e di a n 8 86 4Apple#y, .ooper, et al 1999? 0hillips et al 5005? /eau tr ais 5001 #? @oster et al 1999? *olnar, /erk" a n , et al 5001? /eautr ais, Boyce, *ulder, et al 199E? -esag e et al 199;? .ava n a g h et al 1999 a , 1999 #? .heng 1998? $wahn and 0ott er 5001? 3essler et al 1999? Hi%ayaku " a r and 2a%ku " a r 19996 !hes e findings hav e #ee n report e d for all age s and for #oth suicide and suicide att e " p t 7lder people who "ak e suicide att e " p t s are likely to hav e high er inten t and to use "et h o d s of higher leth ality, and are less likely to survive the physical
se= u el a e of an att e " p t As a cons e = u e n c e , the fraction of older people with historie s of suicide att e " p t is likely to #e s"aller than for young and "iddle) age d popula tio n s Nevert h el e s s , a significant fraction of older people who die #y suicide do hav e histories of suicide att e " p t 42u#e n o witI et al 50016 -ongitudin al follow) up studie s of individu als who hav e "a d e a suicide att e " p t sugg e s t that thos e who "ak e att e " p t s hav e a 0 8 to 5 0 perc e n t risk of suicide within one year of the att e " p t , a suicide risk in e&ce s s of 8 perc e n t after nine years 47wens et al 50056, and higher rat e s of de a t h fro" other caus e s , including ho"icid e, accide n t s and dise a s e 4/eau tr ais 500; a? 7sta " o and -onn=vis t 5001? +awton and @agg 1988? +arris and /arraclou g h 1998? 0eder s o n et al 1998? /eautr ais 500: #6 !wo gen e r al conclusion s can #e draw n her e @irst, the rep e tition of suicide att e " p t is co" " o n and rate s of suicide are high $econ d, prediction, fro" #as elin e char a c t e ris tics, of eith er suicide att e " p t or suicide is poor A possi#le reas o n for this is that the factors that det er "i n e su#s e = u e n t suicidality "ay relat e to tre a t " e n t , life eve n t s , chan g e s in social circu " s t a n c e s and "e n t al health, which occur after the inde& suicide att e " p t and which canno t #e predict e d fro" #as elin e char a c t e ris tics Prior care for ment al health proble m s A cons e = u e n c e of the link #etw e e n "e n t al disord e r and suicidal #eh a vio ur is that "a n y people "aking suicide att e " p t s or dying #y suicide will hav e a history of cont a c t with "e dic al, welfare and relat e d services for "e n t al healt h pro#le " s 4Apple# y, .oop er, et al 1999? /eautr ais 5001 #6 !hes e findings sugg e s t that thos e who die #y suicide and "ak e serious suicide att e " p t s are well known to service s, and their att e n d a n c e and ad "is sio n provid e opport u nitie s for refining tre a t " e n t and "a n a g e " e n t appro a c h e s to "ini"is e suicide risk In particular, it has #ee n esti" a t e d that "ore than 50 perc e n t of suicides that occur shortly after people hav e #ee n hos pit alis e d with "e n t al illnes s could #e prev e n t e d 4Apple# y and $haw 1999? Apple#y, ,enn e h y et al 1999? /urge s s et al 5000? ,ep ar t " e n t of +ealth J-ondonK 50016 Incre a s e d risk with incre a si n % a%e A su#s t a n ti al #ody of res e a r c h has rep e a t e d l y identified "e n t al disord e r s as the stron g e s t risk factors for yout h suicidal #eh a vio ur 4/eau t r ais 199E? @ergus s o n et al 1998 #, 5000, 500:? /eautr ais, Boyce, *ulder et al 199E? /eautr ais et al 199E, 1999 a? /eautr ais 5000c, 500:c? @ergus s o n and -ynskey 1998 a , 1998 #6, and for adult 4Apple#y, .ooper et al 1999? /eautr ais, Boyce, *ulder, et al 199E? /eautr ais 1998 #6 and older adult 4/eau tr ais 50056 suicidal #eh a viour !he contri#ution of psychia tric illnes s to suicide risk incre a s e s with incre a sin g ag e 4/ea u tr ais 1998 #6
+amil& histor& of suicidal beh a vio ur A fa"ily history of suicidal #eh a vio ur is ass ocia t e d with risk of suicide and suicide att e " p t 4/eau t r ais 500:c? .hen g et al 5000? /rent and *ann 50086 2ate s of suicide att e " p t are elev a t e d in the fa"ily "e " # e r s of thos e who die #y suicide, and in the fa"ilies of thos e who "ak e suicide att e " p t s , after "e n t al disord e r s are take n into accou n t !hes e findings sugg e s t that suicidality is tran s "i t t e d within fa"ilies, inde p e n d e n t l y of psychia tric disord e r s 4/rent and *ann 50086 I"pulsive aggr e s sio n "a y play a role in the tran s "i s sio n of fa"ilial suicidal #eh a viour since it is i"plicat e d in psycho p a t h ol o g y, and in fa"ilially shar e d adv er s e environ " e n t s 4/rent and *ann 50086
Ps&ch olo%ical risk factors

.ertain te " p e r a " e n t s , pers o n ality traits, psycholo gic al vulner a #ilities, and cognitive and coping styles "ay act as predis p o sin g factors in suicidal #eh a vio ur !he co" " o n thre a d in thes e psychologic al cons tr uc t s linked with suicidal #eh a viour is that they all predis p o s e the individu al to reac t in neg a tiv e ways to perc eiv e d stre s sful situa tio n s In youn g peopl e a wide rang e of psycholo gic al factors has #e e n ass ocia t e d with incre a s e d risk of suicide and suicide att e " p t !hes e factors includ e low self) est e e " , hopel e s s n e s s , e&tr a v e r sio n, neuroticis ", locus of control, i"pulsivity and i"pulsive violent aggr e s sivity, self) conscious n e s s , social disen g a g e " e n t and cognitive rigidity 4@ergu s s o n et al 5000? 500:? /rent et al 199;? $haffer et al 199E? /eautr ais et al 1999 #? /en%a "in s e n et al 1990? .olson 1995? 0allis and Benkins 1999? >oldne y 1985? de 'ilde et al 199:? 3ienhors t et al 1995? 0earc e and *artin 199:? $pirito and 7verhols e r 1991? Asarnow and >uthrie 1989? .arlson and .antw ell 1985? 3ashd e n et al 199:? $"ith and .rawford 198E? ,iekstr a et al 1998? >roholt et al 50006 .aspi et al 4199E6 hav e report e d that te " p e r a " e n t in thre e) year) olds predicts suicide att e " p t !hos e children ass e s s e d as inhi#ite d at ag e thre e and thos e %udg e d to #e Aunder) controlled at thre e were at incre a s e d risk of later suicide att e " p t s In adults, the pers o n ality traits that hav e #e e n ass ocia t e d with suicidal #eh a vio ur s includ e hop ele s s n e s s , neuro ticis ", an&iet y, ti"idity, cognitive rigidity, i"pulsivity, aggr e s sio n and a stron g sens e of pers o n al indep e n d e n c e 4/eck et al 1990? .lark 199;? .onner et al 5001? ,u#ers t ei n 5001? +arwoo d et al 5001? /eautr ais 5001 #, 50056 @or older adults, suicidal #eh a viour tend s to #e char a c t e ris e d #y such psycholo gic al traits as hop el e s s n e s s , cognitive rigidity, poor ada p tiv e functioning, low Aopen n e s s to e&p erie n c e and a det er "i n e dly indep e n d e n t pers o n al style 4,u#ers t ei n 1998? .lark 199:? @ar#er ow and $hneid " a n 19906 $uch pers o n ality char a c t e ris tics are gen e r ally reg ar d e d as Afi&ed attri#u t e s , which are relativ ely difficult to "odify, i"plying that such traits "ay i"pe d e interv e n tio n efforts ai"e d at prev e n ti n g suicide
!*
+opele s s n e s s is stron gly associa t e d with suicidal idea tio n, suicide att e " p t and suicide 4for review s, see A#ra "s o n et al 5000? 'eisha a r and /eck 19906 , and has #ee n report e d to #e "ore stron gly ass ocia t e d with suicide tha n depr e s sio n 4/eck et al 199:6 +opeles s n e s s is a stron g predictor of suicide in follow) up studie s of 8 to 10 years of inpatie n t s , outp a ti e n t s and suicide att e " p t e r s 4/ea u tr ais 500; a ? /eck et al 1988, 1989, 19906 +opele s s n e s s app e a r s to #e a sta#le psychologic al trait, which "ay #e indep e n d e n t of depr e s sio n, "ay persis t des pit e re"is sion of depr e s sio n 4/rent et al 1998? 2ifai et al 199;6 and "a y occur co"or #idly with a rang e of "e n t al disord e r s 4Boiner et al 5001? /onner and 2ich 19916 +igh levels of hop el e s s n e s s hav e also #ee n show n to occur in succe s siv e episod e s of depr e s sio n 4/eck et al 19886 !hes e o#s erv a tio n s sugg e s t that the e&t e n t of hop el e s s n e s s should #e ass e s s e d , and tre a t e d , inde p e n d e n t l y of "e n t al disord e r s !wo te " p e r a " e n t s , in particular, app e a r to #e ass ocia t e d with suicide and suicide att e " p t in #oth yout h and adults 4/rent et al 199;? Apter et al 1998? 3otler et al 5001? 0lutchik 19986 !hes e are the typ e descri# e d as i"pulsive and<or aggr e s siv e, and the type descri# e d as Aneurotic, which includ e s depr e s siv e and withdr aw n traits 4@ergus s o n et al 5000, 500:? /eau tr ais et al 1999 #6 Individu als with aggr e s siv e and i"pulsive te " p e r a " e n t s are at incre a s e d risk of suicide and suicide att e " p t 4@ergu s s o n et al 5000? Heron a and 0atrick 50006 In the s e individu als, suicidal #eh a vio ur "ay occur in the a#s e n c e of a "oo d disord e r 4Apter et al 19986, and "a y #e ass ocia t e d with antisocial #eh a viour s and conduc t disord e r, alcohol and su#s t a n c e a#us e , i"pulsive #eh a vio ur, high score s on "e a s u r e s of novelty) seeking, and historie s of childhoo d adv er sity 4@ergu s s o n et al 5000, 500:? Heron a and 0atrick 50006 1videnc e fro" epid e "iological, twin, adop tio n and pro# a n d studie s sugg e s t s that #oth i"pulsive #eh a vio ur and trait i"pulsivity show fa"ilial or her e dit a r y tran s "i s sio n 4*eyer et al 5000? Goung et al 5000? 1aves and 1ysenck 1998? -oehlin 1985? 0eder s o n et al 1988? 1ysenck 199E? 'iller" a n et al 1995? -udwig 199;? .ador e t et al 1998? /ierut et al 1998? Iacono et al 1999? 3endler et al 19996 7ther res e a r c h e r s hav e sugg e s t e d that i"pulsivity "a y #e one of the interv e ni n g factors #etw e e n #rain seroto n e r gic activity and aggr e s siv e and suicidal #eh a vio ur 4*ann et al 5001? Heron a and 0atrick 50006 @urth er res e a r c h is ne e d e d to det e r "i n e how i"pulsive< a g g r e s s iv e and novelty) seeking te " p e r a " e n t inter a c t with environ " e n t a l stres s e s to incre a s e the risk of suicidal #eh a viour $tres s) diath e sis "od els of depr e s sio n posit that gen e tic factors, including te " p e r a " e n t , influenc e individu al res po n s e s to stres sful eve n t s 4.ostello et al 5005? *onroe and $i"on s 19916 !hes e "od els sugg e s t that suicide risk is det e r "i n e d #y the pres e n c e of "e n t al disord e r and a diath e sis or trait) like gen e tic ally influenc e d predis p o sition to #eh a v e i"pulsively and aggr e s siv ely 4*ann et al 19996
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2ecen t res e a r c h has e&a "i n e d the e&t e n t to which ther e "ay #e gen e tic factors that shap e individu al differe n c e s in res po n s e to environ " e n t a l stre s s e s 4.as pi et al 500:6 A function al poly"o r p his " of the serot o nin trans p o r t e r 48) +!!6 gen e was found to "od e r a t e the influenc e of stre s sf ul life eve n t s on depr e s sio n !hes e findings sugg e s t a gen e) #y) environ " e n t 4>&16 inter a c tion, in which an individu als way of resp o n di n g to environ " e n t a l stres s e s that occur in childhoo d and in adultho o d is influenc e d #y individu al gen e tic "ak e u p
'eurobiolo%ical risk factors

In curre n t suicide res e a r c h ther e is a stron g focus on the role of gen e tic and #iological factors in the aetiology of suicidal #eh a vio ur s 4for review s, see *ann et al 1999, 5001? /rent and *ann 5008? *ann 500:6 As note d a#ov e , high er rate s of suicide and suicide att e " p t are found in the fa"ilies of individu als with suicidal #eh a viour tha n in the fa"ilies of peopl e withou t suicidal #eh a viour 4/rent and *ann 5008? /rent et al 1988, 199;, 199E? >ould et al 199E, 1998? >arfinkel et al 1985? >ross " a n et al 1991? 2oy 198:? +arkavy) @ried " a n et al 1989? 0feffer et al 199;? >oodwin et al 500;? 'aern et al 500:6 !his finding sugg e s t s that gen e tic factors are involved in suicidal #eh a viour !his view is suppor t e d #y adop tio n and twin studie s Adoption studies show an elev a t e d risk of suicide in the #iological relativ e s of adop t e e s who die #y suicide co"p a r e d with non) suicidal adop t e e s 4for review s, see /rent and *ann 5008? 2oy et al 19996 !win studie s hav e found high er rate s of suicidal #eh a viour s in "on oI yg o tic twins co"p a r e d with diIygotic twins 42oy et al 1991? +a#erla n d t 19E8? Buel) Nielse n and Hide# e c h 1990? Zair 19816 Csing twin design s, studie s hav e sugg e s t e d that up to ;8 perc e n t of the varianc e in suicidal #eh a vio ur "ay #e gen e tic in origin 4$tat h a " et al 1998? 2oy et al 1999? @u et al 50056 !hes e herita #ility esti " a t e s for suicidal #eh a viour are si"ilar to thos e for "a%or psychia tric illnes s e s such as schiIophr e ni a and #ipolar disord e r $eroto nin syst e " dysre g ul a tio n is ass ocia t e d with incre a s e d risk of suicide and suicide att e " p t 4inde p e n d e n tl y of psych o p a t h olo g y6, su#%ectiv e severity of sy"p t o " s , and plann e d suicide att e " p t s of high leth ality 4Institut e of *edicine 5005? *ann 500:? !rask " a n) /endI and *ann 5000? As#erg et al 198E? /rown and >oodwin 198E? .ocarro et al 1989? *ann et al 198E, 199E? $tanley and $tanley 1989? *alone et al 199E? *eltIer et al 198;? Arango et al 19986 -ittle is known, how ev e r, a#ou t the proce s s e s #y which seroto nin and suicidal #eh a viour "ight #e linked Initially it was thoug h t that i"pulsivity or aggr e s siv e #eh a viour "ight #e i"port a n t interv e nin g varia#le s 4As#er g et al 198E? .ocarro et al 1989? *ann et al 198E? Arango et al 1990? 3ety 198E? *ann 19896 +owev er, rece n t work sugg e s t s that low levels of seroto nin "a y #e linked to plann e d , non) i"pulsive, pote n ti ally leth al suicide att e " p t s 4*ann 19986 -ow levels of serot o nin "ay #e associa t e d , principally, with poor i"puls e control rath e r tha n suicidality per
se 40lutchik 1998? $tein et al 199:6, and this linkag e "ay #ett e r e&plain the seroto nin dysr e g ul a tio n o#s erv e d in #oth suicidal and violent #eh a viour Altere d tran s "i s sio n in the nora dr e n e r gic, dop a "i n e r gic, >A/Aergic and gluta " e r gic syst e " s "ay #e associa t e d with suicidal #eh a viour 4Arango et al 199E? 3li"ek at al 1999? 7rdwa y 1999? 7rdw ay, $"ith, et al 199;? 7rdwa y, 'iddow s o n, et al 199;6 !hes e findings are consist e n t with sugg e s tio n s that chronic e&po s u r e to stres sful eve n t s and to psychologic al stre s s lead to dysr e g ul a tio n of the nore pin e p h rin e) specific nucleu s 4!rask " a n ) /endI and *ann 5000? *ann et al 198E? 'eiss et al 199;? +ei" and Ne"e r off 50016 In gen e r al, how ev e r, findings fro" the s e studies hav e #ee n less consist e n t tha n thos e fro" studies of the serot o n e r gic syst e " !here is a nee d for furth er res e a r c h of #oth the seroto n e r gic syst e " and the other neuro tr a n s " i t t e r syst e " s i"plicat e d in suicidal #eh a viour
Childhoo d adve rsit &

!here are clear links #etw e e n e&pos ur e to childhoo d adv er sity and risk of later suicidal #eh a viour a"o n g youn g people 1levat e d rat e s of suicidal #eh a vio ur s are found a"o n g youn g people fro" disadv a n t a g e d and dysfunction al fa"ily #ackgro u n d s , char a c t e ris e d #y such feat ur e s as par e n t al sep a r a tio n or divorc e, pare n t al psycho p a t h ol o g y, a history of se&u al, physic al and e"o tion al a#us e or neglect, i"pair e d par e n t child relation s hip s and inter a c tion, pare n t al discord, and par e n t al violent #eh a vio ur 4@ergu s s o n et al 5000? $ilver " a n et al 199E? /rown et al 19996 !hes e factors app e a r to conv e y an end urin g vulner a #ility to the dev elo p " e n t of "ood disord e r s , su#s t a n c e a#us e and suicidal #eh a viour which persist s into adulth o o d and older adultho o d 4 for review s, see /eautr ais 500: a? >ould et al 500:? $haffer et al 50016 In gen e r al, e&p erie n c e s of childhoo d adv er sitie s ten d to act cu"ula tiv ely, with thos e "os t at risk of suicidal #eh a viour #eing char a c t e ris e d #y "ultiple childhoo d adv er sitie s In addition to associatio n s that hav e #e e n found #etw e e n specific childhoo d adv er sitie s, a series of studie s has e&a "i n e d linkag e s #etw e e n glo# al "e a s u r e s of adv er sity and risks of suicidal #eh a vio ur In gen e r al, incre a s e d risk of suicidal and suicide att e " p t hav e #e e n found a"o n g youn g peopl e e&po s e d to fa"ily environ " e n t s ass e s s e d as #eing glo#ally dysfunction al or adv er s e 4/eau t r ais 199E? @ergus s o n and -ynske y 1998 a? de 'ilde et al 199:? Ada"s et al 199;? Boffe et al 1988? 3osky et al 1990? *artin et al 1998? 2u#e n s t ei n et al 1989? $lap et al 1989? *arttu n e n et al 19956 A New Zeala n d stud y found that risk of suicide att e " p t was high er in childre n fro" disadv a n t a g e d fa"ily #ackgro u n d s char a c t e ris e d #y a co"p o sit e score of childhoo d adv er sity, including socioec o n o "i c disadv a n t a g e , pare n t al historie s of su#s t a n c e a#u s e or offendin g, par e n t al "arit al discord or insta #ility, co"pro "i s e d childre a rin g, and high resid e n ti al "o#ility A"ong thes e fa"ilies, risks of suicide att e " p t incre a s e d with incre a sin g adv er sity 4@ergu s s o n et al 5000? @ergus s o n and -ynske y 1998 a6
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7n the ass u " p ti o n that ther e are caus al links #etw e e n e&pos ur e to fa"ily adv er sity and later suicidal #eh a viour, ther e are at leas t two caus al rout e s #y which this associa tio n "ay occur @irst, the associa tio n "a y reflect a caus al chain in which 4a6 e&po s u r e to fa"ily adv er sity leads to incre a s e d risks of ad%us t " e n t pro#le " s and other difficulties in adoles c e n c e , and 4#6 ad%us t " e n t pro#le " s and other difficulties in adole s c e n c e lead to incre a s e d risks of suicidal #eh a viour Altern a tiv ely, e&po s u r e to childhoo d adv er sity "a y influenc e later susc e p ti #ility to suicidal #eh a vio ur #y decr e a si n g the individu als a#ility to cope with stre s s e s or difficulties in adoles c e n c e !his issue has #ee n e&a "i n e d in a pros p e c tiv e stud y 4@ergu s s o n et al 5000? @ergus s o n and -ynske y 1998 a6, which conclud e d that the weight of evide n c e favour e d a caus al chain e&plan a tio n in which the "a%or contri#ution of fa"ily factors to suicidal #eh a viour aros e #ec a u s e of the influenc e of the s e factors on the individu als psychia tric and social functioning in adoles c e n c e @or adults, co"p a r e d with youth, early childhoo d factors app e a r to #e less influen ti al in risk of suicidal #eh a viour s !he likely rea s o n for this is that, with the pas s a g e of ti"e, the effects of adv er s e childhoo d e&p erie n c e s #eco " e overlaid #y other life e&p e ri e n c e s , res ulting in earlier e&p e ri e n c e s playing a decr e a si n g role in the aetiology of adult suicide Nevert h el e s s , older adults with serious suicidal #eh a viour ten d to hav e historie s of childhoo d adv er sity 4including se&u al a#us e and poor pat er n al care6, sugg e s ti n g that early e&po s u r e to such adv er sity "a y confer enduring vulner a #ility for the dev elop " e n t of "oo d disord e r s and suicidal #eh a viour !he rang e of childhoo d adv er sity factors associa t e d with suicidal #eh a viour overlap s heavily with the known risk factors for %uvenile cri"e, su#s t a n c e a#us e , "e n t al healt h pro#le " s and oth er adv er s e outco " e s for yout h and adoles c e n t s 42utt er and $"ith 19986 !his sugg e s t s that the "a%or life proce s s e s and pathw a ys that lead to risk of suicidal #eh a viour are si"ilar to thos e that lead to "e n t al he alth pro#le " s and other adv er s e outco " e s for youn g people, and i"plies that gen e ric progr a " " e s that att e " p t to a" elior a t e childhoo d adv er sitie s "ay reduc e the risk of suicidal #eh a viour specifically
Ps&ch os o ci al stre ss e s
$uicidal #eh a viour is often prec e d e d #y e&po s u r e to stres sful or adv er s e life eve n t s , esp e ci ally eve n t s that involve sha " e , hu "iliation, loss, defe a t or thre a t 43ienhors t et al 1995? >ould et al 199E? 2u#e n s t ei n et al 1989? Apter et al 199:? *arttu n e n et al 199:? 2ich et al 1991? $haffer 199;? Ada"s et al 199;? /eautr ais et al 1999? /rent, 0erp er, *oritI, /augh e r, et al 199:? de 'ilde et al 1995? ,u#ow et al 1989? >roholt et al 1998? *orano et al 199:? 0feffer et al 1991, 199:? $hafii et al 1988? 'etIler et al 199E6 A"ong youn g people, the "os t co" " o n life eve n t s are interp e r s o n al loss e s or conflicts 4usu ally relation s hip #re ak d o w n s 6 and, less co" " o nl y, legal or disciplinary crises Goung people with suicidal #eh a viour "a y also hav e #ee n su#%ect e d to #oth a high er total nu" # e r of stres s e s and to "or e
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sev er e stres s e s than their non) suicidal peer s 4-es ag e et al 199;? >ould et al 199E? 2u#e n s t ei n et al 1989? de 'ilde et al 1995? ,u#ow et al 1989? 0feffer et al 1991? $hafii et al 19886 @or adults, the key life eve n t s that incre a s e risk of suicidal #eh a vio ur are interp e r s o n a l loss e s and conflicts 4including "arit al sep a r a tio n, serious fa"ily argu " e n t s , une " pl o y " e n t , chan g e of resid e n c e , retire " e n t 6 , financial pro#le " s and %o# pro#le " s 4.hen g et al 5000? /eau tr ais 5001 #? +eikkine n, Iso"e t s a , Aro, et al 19986 $o" e of the life eve n t s that prec e d e serious suicidal #eh a vio ur app e a r to #e gen e r a t e d #y an individu als own #eh a viour $pecific life eve n t s 4sep a r a ti o n, serious fa"ily argu " e n t s , financial pro#le " s and une " pl o y " e n t 6 often app e a r to arise fro" pro#le " s with alcohol In older adults, healt h i"pair " e n t s , so" a tic illnes s e s and declining physic al cap acity play a role in precipita tin g suicidal #eh a vio ur, with so" e evide n c e that physic al he alth pro#le " s play an incre a sin gly influential role with incre a sin g ag e, particularly for "ale s 42u#e n o witI et al 5001? 'aern et al 500:? $Iant o et al 1999? *ac*aho n and 0ugh 19E8? >uohu a 19986 @a"ily discord and conflict are also ass ocia t e d with incre a s e d risk of suicide in the old 4over E8 years 6, and in the old elderly 4over 98 year s6 42u#e n o witI et al 5001? 'aern et al 500:6 @a"ily conflicts "ay aris e in the cont e & t of ageing) relat e d Astres s o r s, and older adults with poor coping and ad a p tiv e skills "a y #e thos e likely to #e "or e vulner a #l e to suicidal #eh a viour A furth e r set of factors ass ocia t e d with suicidal #eh a vio ur s in adults relat e s to various for"s of social inter a c tio n !hos e "aking serious suicide att e " p t s are likely to #e char a c t e ris e d #y high rat e s of social isolation, feelings of loneline s s , poor social suppor t and lack of a close, confiding relation s hip 4/ea u tr ais 5001 #6 !he e&t e n t to which the often poor social circu " s t a n c e s of adult and elderly suicidal individu als aris e fro" their psycho p a t h ol o g y 4particularly, depr e s sio n6 and pers o n ality traits, and the e&t e n t to which it "ight #e possi#le to encour a g e social particip a tion #y at) risk individu als, is an are a in which furth er res e a r c h is ne e d e d
S ocial and dem o% r a p h i c factors

$uicidal #eh a viour is influenc e d #y a rang e of social and de " o g r a p hic factors A%e !here are clear differe n c e s in rate s of suicidal #eh a viour s #y age @or youn g people, the risk of suicide incre a s e s with incre a sin g ag e after pu# e r t y 4>roholt et al 1998? /rent et al 19996 A"ong youth 4ag e d 18 5;6 suicide is "os t co" " o n a"o n g thos e ag e d 18 to 5; years 4'+7 19996 !hus what is often descri# e d as Ayouth suicide 4with the "isp e rc e p ti o n that this is syno n y " o u s with tee n suicide6 "ight "or e accur a t ely #e descri# e d as
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suicide in youn g adults In New Zeala n d , the risk of suicide is high e s t a"o n g "e n ag e d 50 ;; In "os t countrie s suicide rate s hav e always #e e n high e s t a"o n g older adults 4esp e ci ally for thos e age d 98 years and older6 4'+7 19996 In New Zeala n d, how ev e r, the dra " a tic incre a s e in the youth suicide rat e in the "id) 1980 s "e a n t that youth rat e s surp a s s e d thos e of older adults and hav e re" ai n e d higher ever since $uicide res e a r c h and prev e n tio n efforts in the last two deca d e s hav e focus e d on adoles c e n t s and youn g people +owev e r, the progr e s siv e ageing of the popula tio n in the 'est e r n world, including New Zeala n d , "e a n s that #oth a#solut e nu" # e r s and rate s of suicide in older adults are likely to incre a s e as a cons e = u e n c e of the cu"ul a tiv e effects of longer life e&p e c t a n c y, pres s u r e on health reso urc e s , and, perh a p s , an incre a s e d fraction of the older popula tio n with physical illness e s and disa#ilities /end e r >end e r plays a strikingly differe n t role in suicide and suicide att e " p t @e"al e s are "ore likely to "ak e non) fatal suicide att e " p t s , while "ale s are "or e likely to die #y suicide In New Zeala n d this gend e r par a d o & e&ists acros s all age s , including youth 4/eau t r ais 50056, and acros s ethnicities 4/eau tr ais 500: d, 500: e6 +owev er, while "ale s are "or e likely to die #y suicide, when the spec tr u " of suicidal #eh a viour s 4including suicide att e " p t 6 in the popula tion is e&a "in e d , fe" al e s e" e r g e as #eing "or e pron e to suicidal #eh a viour tha n "ales 4@ergus s o n et al 5000? NZ+I$ 500;6 !he associa tio n #etw e e n suicidal #eh a viour and gend e r is thus par a d o &ic alF altho u g h fe" al e s show high er rate s of suicidal #eh a viour, "ales "or e fre=u e n tly die #y suicide !he key to this gend e r par a d o & pro# a #ly lies, largely if not wholly, with gend e r differe n c e s in choice of "et h o d for suicide att e " p t !radition ally ther e hav e #ee n "ark e d differe n c e s in "ale and fe" al e choice s of "e t h o d , with fe"al e s "or e often choosing self) poisoning and "ale s "or e often choosing the "or e leth al "et h o d s of hangin g and vehicle e&h a u s t gas 4/eau t r ais 1999 a , 5000 a , 500:c, 500: d6 !hes e findings hav e pote n ti ally i"port a n t i"plication s given the incre a sin g use #y fe" al e s of highly leth al "e t h o d s such as hangin g and vehicle e&h a u s t gas >iven that young fe"al e s are "or e likely tha n "ale s to "ak e suicide att e " p t s , if the tren d for fe"al e s to use "or e leth al "et h o d s continu e s ther e is the pote n ti al for fe" al e youth suicide rate s to appro a c h , or eve n e&ce e d , thos e of "ale s $thnicit& In New Zeala n d , as in a nu "# e r of countrie s, indige n o u s people ten d to hav e high er rate s of suicide and att e " p t e d suicide 4 see, for e&a " pl e , 3ettl and /i&ler 1991? -ee 5000? $keg g et al 1998? .,. 500:? Indian +ealth $ervice 19996 $uicide rate s are high er a"o n g youn g *ori children, adoles c e n t s , and yout h age d und er 58 year s tha n in their non) *ori pe ers !he elev a t e d risk in *ori app e a r s to #e high e s t a"o n g youn g adult "ale s
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and decline s with incre a sin g age, with this tren d #eing particularly evide n t after th e "id) ;0s 4/eau tr ais 500:6 7lder *ori app e a r relativ ely prot ec t e d fro" suicide co"p a r e d with their non) *ori peer s 4arital status 2isks of suicide are elev a t e d a"o n g "ale s who are divorce d, widow e d or nev er "arrie d 4see, for e&a " pl e , +eikkine n, Iso" e t s a , *arttu n e n , et al 1998? 3posow a 5000? -uo"a and 0ears o n 50056 +owev er, "a n y studie s that hav e e&a "i n e d the ass ocia tion #etw e e n "arit al stat u s and suicide hav e #ee n conduc t e d at an aggr e g a t e level and hav e failed to take into accou n t the e&t e n t to which oth er factors, such as "e n t al illnes s, "a y contri#ut e to "arit al stat u s Intelli% en c e and level of educa ti on In gen e r al, risks of suicide and suicide att e " p t are elev a t e d a"o n g individu als who hav e poor or li"ited educ a tio n 4/eau tr ais 5001 #? -esag e et al 199;? >ould et al 199E6 It is likely that the "a%or rout e #y which poor educ a tio n leads to suicidal #eh a viour is as a result of links #etw e e n socioec o n o "ic factors and "e n t al he alth 4@ergus s o n and -ynske y 1998 a6 In "ale s, risk of suicide has #e e n found to #e invers ely and propor tion a t e l y relat e d to score s on intelligen c e test s conduc t e d in early adulth o o d, with thos e individu als scoring low on such tes ts #eing at incre a s e d risk of su#s e = u e n t suicide 4>unn ell et al 50086 !his associa tio n "ight #e "e dia t e d #y educ a tio n al att ain " e n t , which "a y influenc e occup a tio n al opport u nitie s and inco" e 6eli%ion 2eligious affiliation and religious activity app e a r to prot ec t ag ain s t suicide, with high er rate s of suicide a"o n g thos e withou t religious affiliation 40escos olido and >eorgia n n a 1989? -ester 5000? *aris 19816 It is likely that religious affiliation and religious activity e&ert a prot ec tiv e effect in a nu "# e r of ways, including proscri#ing ag ain s t suicide and pro "o tin g social links, with thes e links and prohi#ition s also decr e a s i n g the risk of psychia t ric disord e r s 4including depr e s sio n, su#s t a n c e a#u s e , offendin g and antisocial #eh a vio ur s6 with which suicide is ass ocia t e d Socio ec o n o mi c statu s /oth aggr e g a t e ) level and individu al) level studie s in differe n t countrie s hav e sugg e s t e d that lower social class and<or socioec o n o "ic disadv a n t a g e are risk factors for suicide and att e " p t e d suicide 4 see, for e&a " pl e , @ergus s o n et al 5000? /eau tr ais 5001 #, 5005, 500:c? @ergus s o n and -ynske y 1998 a? /o&er et al 1998? /ucca et al 199;? >unn ell et al 1998? 0latt and +awto n 5000? /eautr ais et al 1998 d? -ewis and $logg e t t 1998? Bohans s o n et al 19996 @or e&a " pl e , rece n t res e a r c h using the ,anish longitu din al regist e r s 4>oldn e y 500;6 has show n that low inco" e incre a s e s suicide risk, #ut that
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this risk is su#s t a n ti ally att e n u a t e d when "e n t al illness is take n into accou n t -ow inco" e has a stron g e r effect on "ale rath e r than fe" al e suicide risk, sugg e s tin g that "ale s are "or e disadv a n t a g e d #y poor econ o "ic condition s tha n fe"al e s !he findings fro" this stud y clearly sugg e s t that ass ocia tion s #etw e e n "e a s u r e s of social class and suicide risk are likely to #e su#s t a n ti ally over e s ti " a t e d if they are not ad%us t e d for pot e n ti al confoun din g factors, and for "e n t al illnes s in particular =nem pl o & m e n t 2ecen tly, consid e r a #l e att e n tio n has #ee n given to the role of une " pl o y " e n t as a factor that provok e s suicidal #eh a vio ur $tron g clai"s hav e so" e ti " e s #ee n "a d e that chan gin g e"ploy " e n t patt e r n s are respo n si#l e for chan g e s in rate s of suicide 4 see, for e&a " pl e , *orrell et al 19986 /oth ti"e) series analys e s and cas e) control or longitudin al studie s hav e ten d e d to report associa tio n s #etw e e n une " pl o y " e n t and suicide and att e " p t e d suicide with 72s for suicide and att e " p t e d suicide rangin g fro" : to 59, and 0A2s ranging fro" 9 to 88 perc e n t 4 for a review, see 0latt and +awton 5000 6 !he wide rang e in thes e esti" a t e s is likely to #e accou n t e d for #y the e&t e n t to which individu al studie s controlled for the pote n ti ally confou n din g effects of psychia tric disord e r and oth er factors In the pros p e c tiv e .hristch u rc h +ealth and ,evelop " e n t $tudy, une " pl o y " e n t was significan tly relat e d to incre a s e d risks of suicidal #eh a vio ur After ad%us t " e n t for confoun din g and revers e caus ality, this associa tio n was su#s t a n ti ally reduc e d #ut re" ain e d significant 4@ergu s s o n et al 50016 Analysis of cens u s dat a for New Zeala n d 4/lakely et al 500:6 found a two) to thre e) fold incre a s e d risk of suicide a"o n g thos e who were une " pl o ye d !he aut hor s allow that a#ou t half of this associa tio n "ight #e attri#u t a #l e to confoun din g #y "e n t al illnes s, and conce d e that their stud y does not provid e stron g evide n c e for a caus al link #etw e e n e"ploy" e n t and suicide !here is a ne e d for "or e large popula tion studie s using sophistica t e d statis tic al an alys e s to e&plore the nat ur e of the associatio n #etw e e n une " plo y " e n t and suicide Social chan % e !he i"pact of social chan g e and<or distr e s s on suicide rat e s has #ee n e&a "i n e d in a nu "# e r of countrie s 4 for review s, see $tack 5000 a , 5000 #? 1ckersley and ,ear 5005 6 Aggreg a t e ) level studie s hav e sugg e s t e d that "e a s u r e s of downw a r d social "o#ility and indicat ors of nation al or region al econ o "ic decline are ass ocia t e d with incre a s e d risk of suicide 4/ree d 19E:? -a Hecchia et al 199;6 Incre a s e d suicide rate s hav e also #ee n linked with high er fe" al e particip a tion in the workforc e, incre a s e d rat e s of alcohol cons u " p ti o n , and decr e a s e d rat e s of church att e n d a n c e 4*askill et al 500;6 ,isruption s of social ties are also linked to incre a s e d risks of suicide att e " p t In New Zeala n d, @ergu s s o n and -ynskey 41998 a 6 found that youn g people with fre=u e n t 4over four6 chan g e s of schools #y age 1E were : :
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ti"e s "ore likely to "ak e suicide att e " p t s than their peer s without chan g e s of school $i"ilar findings hav e #ee n report e d fro" the Cnited $tat e s 4Buon and 1ns "in g e r 19996 In particular, ther e has #e e n "uch con%ect ur e in the popular "e di a a#ou t the contri#u tio n of various social chan g e s to rece n t incre a s e s in youth suicide rat e s !his issu e was addr e s s e d in a #ook co" "is sio n e d #y Acade "i a 1urop a e a 42utt er and $"ith 19986 to consid e r evide n c e on whet h e r psych o s o ci al disord e r s 4including suicidal #eh a viour6 a"o n g youn g people had #eco " e "or e or less prev al e n t in the last 80 years , and to e&plore caus al e&pla n a tio n s for any chan g e s found !he auth or s o#s erv e d that suicide rate s a"o n g youn g "ale s had incre a s e d since the 1980 s at the sa " e ti"e that suicide rat e s a"o n g older adults were falling !he auth or s not e that, des pit e consid e r a #l e res e a r c h , ther e were no clear e&plan a tio n s for this incre a s e +owev er, they sugg e s t e d that e&pla n a tio n s for the incre a s e d yout h suicide rat e s were likely to #e found in incre a s e d rat e s of depr e s sio n, and su#s t a n c e a#us e 7ther possi#le e&pla n a tio n s sugg e s t e d could #e the role of antisocial #eh a viour, the influenc e of suicidal "od els within the fa"ily or in "as s "e dia, the incre a s e in fa"ily conflict and decline in fa"ily supp ort ass ocia t e d with chan g e s in fa"ily struct ur e , the effect of an e&t e n d e d period of social dep e n d e n c e , and the likely effect of chan gin g societ al circu " s t a n c e s in gen e r al ;ccup a tio n al %roup A series of studie s has identified particular occup a tio n al group s with incre a s e d risk of suicide !hes e group s includ e police, "iner s, thos e in the "e dic al profes sio n 4doctor s, nurs e s , phar " a ci s t s , dentis t s6, far" e r s and vet erin a ri a n s 4/o&er et al 1998? 3elly and /unting 1998? 3posow a 1999? $tack 5001? +awton et al 1998? -angley and $tep h e n s o n 50016 +owev er, not all studie s identify the sa " e occup a tio n al group s as having elev a t e d risks, and thes e differe n c e s "ay reflect differe n c e s in the e&t e n t to which studie s controlled for the pote n ti ally confoun din g effects of age, gend e r , "arit al stat u s and relat e d factors In part, the elev a t e d risk of so" e occup a tio n al group s "ay reflect their rea d y acce s s to highly leth al "e t h o d s of suicide and<or the stres sful natur e of their work Nevert h el e s s , the identification of high) risk occup a tio n s sugg e s t s that it "ight #e possi#le to targ e t suicide prev e n tio n efforts at thos e occup a tio n al or profes sio n al group s , or, at an orga nis a tio n al level, at co"p a ni e s e"ploying large nu "# e r s of workers in high) risk occup a tio n s =rba nicit&>ruralit& !here are co"pl e& relation s hip s #etw e e n suicide rat e s and ur#a nicity<rur ality !hes e rate s ten d to #e confou n d e d #y the effect s of age, race and gend e r, #ut often the s e effects are not take n into accou n t in ur#a n rural an alys e s of suicide dat a 4see, for e&a " pl e , Lin, 500:? @ranc e s , 198E? 0res #yt e ri a n $upport $ervice s 1989? *iddleto n, 500:? .aldw ell, 500;? $ingh, 5005 6 In gen e r al, in 'est e r n societies rat e s of suicide tend to #e
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high er in rural co"p a r e d to "or e dens ely popula t e d region s !aking other factors into accou n t , living in rural are a s ten d s to decr e a s e suicide risk for fe" al e s #ut incre a s e suicide risk for "ale s 1&plan a tio n s for high er rate s in rural are a s "a y lie with the gre a t e r availa#ility of firear " s , poor er acce s s to "e n t al health and e" e r g e n c y "e dic al service s , high er rate s of "e n t al and physical illness, stres sful life situ a tion s 4eg, the i"pact s of rural econ o "ic downt ur n s 6, gre a t e r stig" a tis a tio n of thos e with "e n t al healt h pro#le " s , and reluct a n c e to seek help
Social factors releva n t to suicide preve n tio n in 'ew (ealan d

In New Zeala n d the *inistry of +ealth has #e e n particularly inter e s t e d in the e&t e n t to which specific he alth outco " e s "ay #e det e r "i n e d #y social and econ o "ic condition s Agains t this #ackgro u n d , the *inistry co" "i s sion e d a series of report s specifically to e&a "i n e the e&t e n t to which rece n t suicide tren d s in New Zeala n d hav e varied in relation to chan g e s in a rang e of socioec o n o "ic factors 4.ollings et al 50086 >iven their relev a n c e , the "a%or findings and conclusion s fro" thes e report s are su " " a ri s e d #elow A selectiv e review of sociological litera t u r e su " " a ri s e d the social, econ o "ic, cultur al and other popula tion) level influenc e s on suicide that hav e #ee n descri# e d in the intern a tio n al literat u r e 4*askill et al 500;6 A large nu "# e r of possi#le influenc e s were e&plor e d +owev er, high consist e n c y a"o n g studie s was found only for the associa tio n #etw e e n "e n t al illnes s and suicide, supp ortin g the findings of New Zeala n d studie s in this are a Inconsist e n t res ults were found for an effect on suicide for popula tion fertility rate s , differe n c e s in ur#a n and rural suicide rate s acros s countrie s, educ a tio n levels, inco " e ine=u ality, une " pl o y " e n t rate s , fe" al e la#our) force particip a tion, periods of econo "ic e&p a n sio n, cri"e, ho"icide and violenc e, and the =uality and availa#ility of "e n t al healt h service s !he litera t u r e review conclud e d that so" e of the social and econ o "ic indicat ors showing possible associa tio n s with incre a s e s in suicide rat e s supp ort e d the relev a n c e to suicide of reduc e d social integr a tio n and social cons tr ain t as a char a c t e ris tic of societ y +owev er, it app e a r e d that it was not the a#solut e char a c t e ris tics of society within this typ e of do" ain, #ut rath e r the pac e and e&t e n t of social chan g e and the life tra%ectorie s of particular su#gro u p s of the popula tion within chan gin g "acro s o ci al circu " s t a n c e s that were esp e ci ally relev a n t to o#s erv e d patt e r n s in suicide rate s intern a tio n ally A secon d study e&a "in e d associatio n s #etw e e n chan g e s in social factors that could #e see n as "ark e r s of asp e c t s of New Zeala n d societ y and chan g e s in suicide rate s 4.ollings et al 50086 !his stud y found that suicide rate s incre a s e d over all during the sa " e period in which "ark e r s of social chan g e also chan g e d , in gen e r ally consist e n t directions !he "ark er s inves tig a t e d were "arria g e rate s , fe"al e la#our) force participa tio n rat e s , decr e a si n g fertility rate s , cri"e violenc e and ho"icid e, and i""igr a tio n
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patt e r n s !he econo "ic indicator s e&plor e d were une " plo y " e n t rate s , the econ o "ic #usin e s s cycle and inco" e ine=u ality +owev e r, no si"ple associa tio n was found #etw e e n any of thes e factors and suicide rate s in New Zeala n d !he auth or s conclud e d that their o#s erv a tio n s provid e d only a "od e s t degr e e of suppor t for the notion that chan g e in social conditions in gen e r al "ight #e linked with chan g e s in suicide rat e s A third study co"p a r e d econo "ic cont e & t u al factors and chan g e s in suicide rate s in New Zeala n d and @inland and e&a "i n e d institution al arra n g e " e n t s and policy conditions that "a y hav e contri#ut e d to differe n c e s in suicide rate s a"o n g young "e n in thes e countrie s 4+owd e n) .hap " a n et al 50086 !he two gover n " e n t s de alt differe n tly with a "a%or econo "ic rece s sion in the late 1980 s and early 1990 s In the dec a d e prior to the rece s sion New Zeala n ds welfare stat e chan g e d to a Asafet y net "od el, wher e a s @inland "aint ain e d a "or e co"pr e h e n s iv e appro a c h In New Zeala n d during the 1980 s and 1990 s inco" e ine=u ality incre a s e d wher e a s in @inland it did not +owev er, this stud y failed to provid e evide n c e that the diverg e n t policies of the two countrie s had differe n t i"pac t s on "ale yout h suicide rat e s 7ne stud y e&plor e d the e&pla n a t o r y fra" e w o rk s used #y *ori lead e r s in *ori "e n t al healt h practice and theory to e&plain suicide 4+irini and .ollings 50086 !he key e&plan a t o r y do" ai n s were rapid social and intra) group chan g e s in social value s and nor "s , and in gend e r roles? the influenc e of "od e r n intern a tio n al Ayouth cultur e ? alien a tio n fro" #oth Atradition al *ori cultur e and social institution s and fro" "ains tr e a " societ y? poor self) conc e p t a"o n g *ori, and *ori youth in particular? and the re) e" e r genc e of *ori cultur al identity and its dyn a "ic natur e in a chan gin g world *ent al illnes s, pro "in e n t in the 0 keh psychia tric discour s e on suicide, was not a pro "in e n t the " e !he auth or s argu e d the i"port a n c e for suicide prev e n tio n of #ett e r integr a ti n g the socio) cultur al and "e n t al health "od els of suicide !he final study e&plor e d the relation s hip #etw e e n tren d s in suicide rate s and a rang e of socioec o n o "ic indicat ors in New Zeala n d , during four interv alsF 1981 8;, 198E 89, 1991 9; and 199E 99 4@ergu s o n et al 500:6 !hes e interv als spa n a period of rapid "acro s o cial chan g e in New Zeala n d , during which ther e was der e g ul a tio n of the financial sector, reorg a nis a tio n of the stat e sector, introdu c tion of a flatt e n e d ta& syst e " , privatis a tion of "a%or utilities, user charg e s for gover n " e n t service s and a restruc t u r e d la#our "ark e t !he study found that une " pl o y " e n t incre a s e d risk of suicide two) to thre e) fold co"p a r e d with #eing e"ploye d , #ut sugg e s t e d that a#ou t half of this associa tio n "ight #e attri#ut e d to "e n t al illnes s 4/lakely et al 500:6 Althoug h the aut hor s of this series of report s found only one clear linkag e 4#etw e e n une " plo y " e n t and suicide6, they conclud e d that all the studie s sugg e s t e d that social factors are relev a n t to suicide !hey argu e that thes e findings provide evide n c e that suicide prev e n tio n canno t #e left entirely to clinical interv e n tio n s !hey allow, how ev e r, that it is not clear fro" their studie s, or fro" intern a tio n al studie s, what social) level interv e n tio n s , if any,
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will hav e a de "o n s t r a #l e and specific effect on suicide rate s , eith er at a popula tion level, or in specific su# )group s
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! 6esilienc & and Protec tiv e +actor s

Althoug h "uch rece n t res e a r c h into suicidal #eh a viour s has focus e d on e&ploring risk factors, ther e has #e e n growing inter e s t in Aprot ec tiv e factors and Aresiliency 4for youth suicide in particular6 !his inter e s t has #e e n "otiv a t e d #y the o#s erv a tio n that "a n y people with e&po s u r e to risk factors do not dev elop suicidal #eh a viour s @or e&a " pl e , of thos e with depr e s sio n, only a "inority dev elo p suicidal #eh a vio ur 4@ergu s s o n et al 500:6 $uch o#s erv a tio n s sugg e s t that ther e "a y #e a rang e of prot ec tiv e factors that act to "itiga t e the effect s of e&po s u r e to risk factors A focus on resiliency to suicidal #eh a vio ur has also arise n fro" 4a6 the view that risk factor res e a r c h is overly neg a tiv e , and<or 4#6 the #elief that solutions to the pro#le " of suicide can #e addr e s s e d #y discov ering factors that contri#u t e to the resiliency of people to adv er sity !his argu " e n t has #ee n applied to yout h suicide in particular !hes e ass u " p ti o n s hav e led to the dev elo p " e n t of a litera t u r e which has "a d e stron g clai"s a#ou t the ways in which various factors "a y contri#ut e to resiliency to suicidal #eh a vio ur in youn g people 4/orowsky et al 1999, 5001? /lu" et al 500:? >uiao and 1sparI a 19986 +owev er, des pit e the app e al of this literat u r e 4/orowsky et al 19996, ther e has #ee n relatively little res e a r c h directly focusing on resiliency and suicidal #eh a vio ur *any of the factors sugg e s t e d as prot e c tiv e factors for suicidal #eh a vio ur hav e #ee n specula tiv e, or hav e #ee n e&tr a p ol a t e d fro" res e a r c h in other fields !here has also #e e n a confusing lack of clarity and consist e n c y in the langu a g e used @or one thing, the factors cited as resiliency factors hav e often app e a r e d to #e "er ely positive ways of descri#ing risk factors @or e&a " pl e , in a stud y of youth, Aconn e c t e d n e s s with par e n t s is cited as prot e c tin g agains t suicide att e " p t 4/lu" et al 500:6 Get Aconn e c t e d n e s s with par e n t s "ay #e view e d as a positive description of the =uality of pare n t child relation s hip s, wher e a s Apoor par e n t child relations hip s, a well) recog nis e d risk factor for suicidal #eh a vio ur, is perc eiv e d as #eing a neg a tiv e ter " !hus ther e has #ee n a growing literat u r e that tend s to i"ply that the stud y of resiliency and prot e c tiv e factors is, in so" e way, "or e effective and insightful than the study of risk and vulner a #ility 4/orowsky et al 1999? 2esnick et al 1999? 2esnick 5000? Luinn 1999? ,avis 19996 2ecen tly ther e hav e #ee n sever al i"port a n t review s of resilienc e which trac e the history of res e a r c h in this field and which clearly define the various conc e p t s use d 4-uth ar and .icchet ti 5000? -uthar et al 5000? -uthar 500:6 A2esilienc e is define d as Apatt e r n s of positive ada p t a ti o n in the cont e & t of risk or adv er sity A2esilienc e re=uire s two fund a " e n t a l %udg e " e n t s F 416 that a pers o n is Mdoing okayN, and 456 that ther e is now or has #e e n significant risk or adv er sity to overco " e 4*ast e n and .oats w or t h 1998, =uot e d in *aste n and 0owell 500:6 -uthar also "ak e s it clear that Aresilienc e is not a pers o n ality trait, #ut, rath e r, a description of a gen e r al
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patt e r n of #eh a vio ur A.o"p e t e n c e is define d as Aa track record of effectiv e perfor " a n c e in dev elo p " e n t a l tasks that are salient for people of a given age, societ y or cont e & t, and historical ti"e 4*ast e n and .oats w ort h 19986 !he issue s of how co"p e t e n c e should #e define d, and #y who ", and appro pria t e definitions in differe n t cultur al setting s , are still "at t e r s for de# a t e 4-uthar et al 5000? *aste n and .oatsw or t h 1998? 2utt er 5000? -uthar 1999? *aste n 1999, 50016 'ithin this resiliency fra" e w o rk, risk and adv er sity are view e d as thre a t s to the dev elo p " e n t of co"p e t e n c e $tudie s of resilienc e hav e ten d e d to take eith er a Avaria#le) #as e d appro a c h or a Aperso n) #as e d appro a c h 4*ast e n and .oats w or t h 1998? *aste n 50016 Haria#le) #as e d appro a c h e s e&a "i n e links #etw e e n co"p e t e n c e , adv er sity and pot e n ti al prot ec tiv e factors 4*ast e n and 0owell 500:6 0erson) #as e d appro a c h e s focus on identifying people who "e e t criteria for resilienc e, and whos e life histories and individu al char a c t e ris tics are then studie d, often #y contr a s tin g the " with people with si"ilar e&po s u r e to adv er sity who hav e suffer e d relativ ely poor outco " e s !hes e review s of resilienc e in childre n and young peopl e hav e consist e n tly identified thre e class e s of individu al and cont e & t u al prot ec tiv e factors which char a c t e ris e resilient individu alsF
individual attributes including cognitive a#ilities 4eg, IL score s , e&ec u tiv e functioning skills6, self perc e p tio n s of co"p e t e n c e 4eg, self) est e e " 6 , te " p e r a " e n t and pers o n ality 4eg, ada p t a #ility, socia#ility6, self) regula tio n skills 4eg, i"puls e control6 and positive outlook on life 4eg, hop efuln e s s 6 relationships including =uality of pare n tin g, clos e relation s hip s with co"p e t e n t adults 4eg, par e n t s , relativ e s , "e n t o r s 6, conn e c tion s to pro) social pe ers community resources and opportunities including good schools, conn e c tion s to pro) social orga nis a tio n s 4eg, religious group s 6, neigh# o u r h o o d =uality, and =uality of social service s and he alth care 4*ast e n and 0owell 500:6
!hes e =ualities "ay all #e view e d as resourc e s that count e r # al a n c e adv er sity or "od e r a t e the i"pact of risk factors or adv er sity on select e d outco " e s It is useful to look at the ways in which the s e definitions can #e applied to suicide res e a r c h !hus e&po s u r e to a set of factors "a y #e see n as incre a sin g vulner a #ility to suicidal #eh a vio ur 1&pos ur e to se&u al a#us e during childhoo d, for e&a " pl e , "ay incre a s e the risk of later suicidal #eh a vio ur in thos e who are depr e s s e d !he alter n a tiv e position is that thos e who are depr e s s e d #ut do not #eco " e suicidal are Aprot ec t e d #y factors that incre a s e their resiliency to suicidal #eh a viour s !hes e argu " e n t s are, to so" e degr e e , interc h a n g e a # l e @or e&a " pl e , if social
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supp ort and social conn e c t e d n e s s contri#u t e to resiliency to suicidal #eh a vio ur a"o n g thos e who are depr e s s e d , the n the a#s e n c e of social supp ort and conn e c t e d n e s s "ay #e descri# e d as conferring vulner a #ility to suicidal #eh a viour when depr e s s e d +owev er, the ways in which factors are conc e p t u alis e d and "e a s u r e d could favour a particular interpr e t a ti o n @or e&a " pl e , it "ay "ak e "or e sens e to descri# e e&pos ur e to childhoo d se&u al a#us e as incre a sin g vulner a #ility to suicidal #eh a viour tha n to descri# e an a#s e n c e of e&pos ur e to se&u al a#us e as conferring resiliency to suicidal #eh a vio ur An alter n a tiv e appro a c h is to propos e "od els in which the vulner a #ility or resiliency factor acts inter a c tiv ely with the e&po s u r e varia#l e? for e&a " pl e , depr e s sio n In their an alysis of the aetiology of depr e s sio n, /rown and +arris 4199 86 propos e d a distinction #etw e e n vulner a #ility and provoking factors, and argu e d that depr e s sio n dev elop s only in thos e who are e&pos e d to #oth vulner a #ility factors and provoking factors !his argu " e n t "ay #e use d to e&plain the aetiology of suicidal #eh a viour #y sugg e s tin g that depr e s sio n is a provoking factor that enco ur a g e s the ons e t of suicidal #eh a vio ur in thos e who are vulner a #l e to this #eh a viour 2utt er 419886 has propos e d a si"ilar inter a c tiv e "od el, in which prot ec tiv e factors are thos e that are #en eficial to individu als who are e&pos e d to a risk factor #ut that confer no 4or less6 #en efit to thos e who are not e&pos e d to the risk factor !his argu " e n t "a y #e used to e&plain suicidal #eh a viour #y sugg e s ti n g that prot e c tiv e factors are thos e that "itiga t e ag ain s t the dev elo p " e n t of suicidal #eh a vio ur in thos e who are depr e s s e d , #ut hav e no or less effect on thos e who are not depr e s s e d A rece n t New Zeala n d study has att e " p t e d to addr e s s so" e of thes e issu e s using dat a gat h e r e d during a 51) year longitu din al study of a #irth cohort of over 1000 youn g peopl e 4@ergu s s o n et al 500:6 !his analysis identified a series of factors that acte d to e&ac e r # a t e or "itiga t e risks of suicidal #eh a vio ur a"o n g young peopl e with depr e s sio n !hes e factors includ e d a fa"ily history of suicidal #eh a vio ur, childhoo d se&u al a#us e , neuro ticis ", novelty) seeking, self) est e e " and peer affiliations 0ositive configur a tio n s of thes e factors 4no fa"ily history of suicide, no childhoo d se&u al a#us e , low neuroticis ", low novelty) seekin g, high self) est e e " and a#s e n c e of devia n t peer affiliations6 incre a s e d resiliency to suicide att e " p t , wher e a s neg a tiv e configur a tio n s of thes e factors act e d to incre a s e vulner a #ility to suicidal #eh a vio ur !hes e findings sugg e s t that factors relating to the e&p e ri e n c e of childhoo d trau " a , fa"ily factors, pers o n ality factors, and the natur e of peer relation s hip s "ay act in ways that eith er e&ac e r # a t e or "itiga t e risks of suicidal #eh a viour s !he factors that so" e res e a r c h e r s hav e sugg e s t e d provid e prot ec tion agains t the dev elop " e n t of suicidal #eh a viour s 4/orowsky et al 1999, 5001? /lu" et al 500:? >uiao and 1sparI a 19986 are consist e n t with the #roa d "od el of resiliency descri# e d in the rece n t "a%or review s outline d a#ov e 4-uthar and .icche t ti 5000? -uthar et al 5000? -uthar 500:6 !hes e factors
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includ e ada p t a #l e te " p e r a " e n t , good self) est e e " and good pro#le ") solving skills 4ie, individual attributes 6? a good e"o tio n al relations hip with at leas t one pers o n in the fa"ily 4ie, relationships 6? good social supp ort and social netw ork? positive school e&p erie n c e s ? and spiritu al faith 4ie, community resources and opportunities 6 4/orowsky et al 1999, 5001? >uiao and 1sparI a 19986 In New Zeala n d , /enn e t t et al 450056 conduc t e d a =ualita tiv e study of 59 young peopl e att e n di n g an Auckland e" e r g e n c y dep a r t " e n t following a suicide att e " p t !his study sugg e s t e d that the factors contri#utin g to recov er y after suicide att e " p t includ e d seeking help fro" profes sion als and peer s, practic al pro#le ") solving skills, thinking positively, and a will to live In contr a s t to the curre n t inter e s t a#ou t prot ec tiv e factors in yout h suicide, ther e has #e e n relativ ely little res e a r c h inter e s t in the role of prot e c tiv e factors for suicide a"o n g adults An e&ce p tio n to this has #ee n res e a r c h e&a "i nin g the links #etw e e n suicide risk, "arria g e and childre n 4+oyer and -und 199:6 !his res e a r c h sugg e s t s that "arria g e prot e c t s ag ain s t suicide for "ale s 4Lin et al 500:? +oyer and -und 199:? +awton 50006, #ut that for fe" al e s , #eing a pare n t rath e r tha n #eing "arrie d is a prot e c tiv e factor that "ini"is e s risk of suicidal #eh a vio ur 2eligious affiliation and participa tio n in religious activities app e a r to prot e c t agains t suicide, pres u " a # l y #y proscri#ing agains t suicide and activities 4such as alcohol a#us e 6 that are precurs o r s to suicidal #eh a viour, and #y pro "o tin g social linkag e s 40escos olido and >eorgia n n a 19896 $tudie s of older adult suicide sugg e s t ther e is a rang e of pot e n ti al prot ec tiv e factors, includingF

a confiding, supp ortiv e relation s hip social suppor t, social conn e c t e d n e s s and social inter a c tio n, including particip a tion in orga nis a tio n s having a ho##y good coping and ada p tiv e skills good physical and "e n t al health ade = u a t e pain relief good palliative care, and tre a t " e n t of depr e s sio n for thos e with ter "in al illnes s e s early, ad e = u a t e and sust ain e d tre a t " e n t and "a n a g e " e n t of depr e s sio n stron g religious and<or spiritu al value s ade = u a t e supp ort following #ere a v e " e n t recog nition of, and respit e fro", fa"ily discord and conflict restrict e d acce s s to "e a n s of suicide, esp e ci ally guns, for older adult "ale s 4'aern et al 5005, 500:? 2u#e n owitI et al 5001? .onwell 5001? 0ears o n and .onw ell 1998? $Iant o 500:? .aine and .onwell 50016
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In New Zeala n d , a"o n g *ori, ag e e&ert s a prot e c tiv e effect, with suicide risk "ark e dly lower a"o n g *ori age d ;8 and older tha n a"o n g y oung e r *ori and a"o n g non) *ori adult peer s @urth er res e a r c h is re=uire d to e&plore the specific factors that confer prot e c tion agains t suicide a"o n g older adult *ori *ore gen e r ally, the li"ited res e a r c h evide n c e sugg e s t s that social att a c h " e n t s and social o#ligation s "ay for" i"port a n t prot e c tiv e factors agains t suicidal #eh a vio ur 2elatively little res e a r c h has focus e d on identifying individu al, fa"ily and co" " u ni t y factors that "a y prot e c t agains t the dev elop " e n t of suicidal #eh a viour, altho u g h inter e s t in this issue has rece n tly incre a s e d !he consid er a tio n s outline d in this section sugg e s t that the issu e s of vulner a #ility and resiliency to suicidal #eh a viour are very co"ple & and should take into accou n t #oth the conce p t u a lis a tio n of "e a s u r e " e n t s and "od els of the pathw a ys linking risks of suicidal #eh a vio ur to other factors It cann o t si"ply #e ass u " e d that a Apositive way of looking at the issu e 4via resiliency6 is prefer a #l e to a Aneg a tiv e pers p e c tiv e 4via vulner a #ility6, or vice vers a !here is a nee d for "or e res e a r c h which focus e s on resilienc e and prot ec tiv e factors for suicidal #eh a viour in adultho o d !here is also a nee d for integr a tiv e res e a r c h that looks at inter a c tion s of "ultiple prot ec tiv e factors, and for res e a r c h that incorpor a t e s gen e tic and #iological factors into vulner a #ility and resiliency "od els
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" Cultur al Issues

2ate s of suicide in New Zeala n d provid e co"p elling evide n c e that cultur al issue s are relat e d to suicidal #eh a viour @or e&a " pl e , co"p a r e d to their non) *ori pe ers , *ori yout h 4"ale and fe"al e6 are over) repr e s ent e d in suicide and suicide att e " p t statis tics, while older *ori app e a r to #e prot e c t e d fro" suicide !hes e o#s erv a tio n s sugg e s t that a New Zeala n d suicide prev e n tio n stra t e g y "us t includ e, as a "a%or o#%ective, "e a s u r e s to reduc e ine=u alities in suicidal #eh a vio ur for a rang e of populatio n s define d #y age, gen d e r and eth nicity !his section e&a "i n e s a series of cultur al and relat e d issu e s that "ight #e consid er e d in dev eloping and i"ple " e n ti n g a nation al suicide prev e n tio n stra t e g y, and in cond uc tin g res e a r c h a#ou t suicidal #eh a viour with *ori, 0acific people s , and other ethnicities relev a n t to New Zeala n d
4 ori
A nation al suicide prev e n tio n stra t e g y nee d s to #e design e d to #e consist e n t with *ori ne e d s and e&p e c t a tio n s , to i"prov e *ori he alth a nd to pro "o t e *ori dev elo p " e n t !his involve s using the !reat y of 'aitan gi to und e r pin the strat e g y, taking action to reduc e ethnic disp arities in rate s of suicidal #eh a vio ur, and e"ployin g the *ori conc e p t s of hauor a, wh nau and wh nau ora In particular, the !reaty relation s hip #etw e e n *ori and the .rown is #as e d on thre e principlesF

part n e r s hip 4working with *ori co" " u ni ti e s to dev elo p appro pria t e healt h pro "o tio n and he alth "aint e n a n c e auth orities 6 particip a tion 4involving *ori in the dev elop " e n t and i"ple " e n t a ti o n of a nation al strat e g y, and relev a n t service delivery6 prot e c tion 4ens urin g he alth and social disparitie s and ine=uities are "ini"is e d6
!he dev elo p " e n t of a nation al suicide prev e n tio n strat e g y re=uire s consid er a tio n of the cultur al cont e & t of *ori and the "e a nin g associa t e d with identifying as *ori !here is consid er a #l e diversity in identity, accultur a tio n and lifestyle a"o n g *ori and it canno t #e ass u " e d that all *ori people who are suicidal are si"ilar in ter " s of the pers o n a l "e a ni n g they ass ocia t e with #eing *ori, nor can it #e ass u " e d that such pers o n al "e a nin g contri#ut e s to suicidal #eh a viour .ultur e plays a significant role in the "a nifes t a tio n of illness 4,urie 1999, 19986 In particular, specialist *ori input shou ld #e soug h t arou n d issu e s of identity for tan g a t a whaior a 4* ori cons u " e r s 6, protocol 4eg, for post) "ort e " s 6, and preocc u p a ti o n s with a sens e of failure on cultur al groun d s 4for issu e s relating to loss of individu al or collective "a n a for suicide att e " p t e rs, or for thos e #er e a v e d #y suicide6
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1&plan a tio n s for suicidal #eh a vio ur a"o n g *ori are often soug h t #eyo n d psychia tric illnes s e s , in the real " s of socioec o n o "ic disparitie s and interg e n e r a t i o n al disadv a n t a g e 4,urie 5001 a , 5001 #? +irini and .ollings 50 08? -awson !e Aho 19986 2ecog nis e d risk factors for suicidal #eh a vio ur 4poor socioec o n o "i c stat u s , educ a tio n al disadv a n t a g e , e&po s u r e to violenc e and a#u s e , disrup tion s in fa"ily wh nau during childhoo d and adoles c e n c e 6 "ay #e co"p o u n d e d for so" e *ori # y a history of tri#al dispos s e s si o n and trau " a !radition al roles for *ori as a collective cultur e involved lead e r s hip or prot ec tion, and guar di a n s hip of tri#al resourc e s and social group s $tres s and reduc e d cap a city or acce s s to tradition al sourc e s of coping with pro#le " s "a y result in *ori #eing overw h el " e d #y the de " a n d s of "od e r n societ y, withou t a clear sens e of purpo s e , particularly if ther e is a #elief that *ori hav e #ee n "argin alis e d >iven this historical cont e & t, and taking into accou n t diversity a"o n g * ori, dev elo p " e n t of a suicide prev e n tio n stra t e g y for New Zeala n d nee d s to consid er the following issue s F
the ne e d to work within the fra" e w o rk of the !reaty of 'aitan gi to addr e s s issue s for *ori, and, particularly, to reduc e he alth and s ocioeco n o "ic ine=uities the ne e d to dev elop prev e n tio n and tre a t " e n t services that are respo n siv e to the ne e d s of *ori 4this "ay "e a n provision of #oth "ains tr e a " and kaup a p a *ori suppor t, health and "e n t al health service s6 in dev elo pin g tre a t " e n t and "a n a g e " e n t "od els for thos e with suicidal crises, taking into accou n t prefer e n c e s for the pres e n c e or suppor t of wh nau or significant other s in dev elo pin g services , giving *ori the opport u nity to #e tre a t e d #y *ori, to hav e cultur al advisors pres e n t at ass e s s " e n t , and taking into consid er a tio n issu e s of unre s olv e d grief and<or loss of cultur al stat u s 4"a n a 6
$uicide prev e n tio n service s for *ori could #e dev elo p e d within e&isting *ori co" " u ni t y dev elo p " e n t , healt h, welfar e or suicide prev e n tio n servic es, with faith) #as e d orga nis a tio n s , or within "ains tr e a " services , and "ay involve dev elo pin g or enh a n cin g specialist "e n t al healt h service s so that *ori people who are suicidal can #e offere d the service of specialist *ori "e n t al healt h workers .urren tly such services "a y #e found a"o n g *ori staff in health service s , ,+/ specialist *ori "e n t al healt h tea " s , staff at *ori healt h units att a c h e d to hos pit als, iwi health provid er s 4eg, * ori co" " u ni t y supp ort workers6, iwi netw orks, and N>7 *ori healt h and social service s .olla#or a tiv e "e n t al health and suicide prev e n tio n services ne e d to specify clearly individu al roles and resp o n si#ilities in cons ult a tio n with the individu als conc er n e d and the wh nau and<or fa"ily .ollective notions of *ori ident ity "a y "e a n that individu alistic service s are inappro pria t e for so" e *ori !here are sever al are a s in which service s
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"ay ne e d to #e tailore d to ens ur e at) risk *ori receive pro " p t and appro pria t e tre a t " e n t !hes e are a s includ e crisis respo n s e service s , in which tea " s "ay #e train e d #y *ori healt h profes sio n als to ens ur e early interv e n tio n occurs? and alcohol and oth er drug service s and "e n t al he alth service s, for *ori with co"or #id su#s t a n c e a#u s e and "e n t al health pro#le " s
Pacific peopl e s
!here is little New Zeala n d res e a r c h a#ou t suicidal #eh a viour a"o n g 0acific group s in New Zeala n d !he e&ce p tion is for young $a"o a n s 4!iatia and .ogg a n 5001? 'ilson and 1verts 1998? 0ulotu) 1nde " a n n et al 500;? *ahina 50056 !he dev elop " e n t of a nation al suicide prev e n tio n stra t e g y in New Zeala n d which is res po n siv e to the nee d s of 0acific people s re=uir e s consid er a tio n of their cultur al cont e & t s and #eliefs !heir #eliefs a#ou t "e n t al illnes s, including suicide, lead to a view of "e n t al illnes s, and of suicide, that often differs fro" 'est er n views 0acific popula tio n s in New Zeala n d are het er o g e n e o u s and cultur ally divers e , and perc e p tio n s a#ou t suicide and "e n t al he alth "ay differ fro" group to grou p !here "ay also #e gen e r a tio n al differe n c e s in views of illness and suicide, particularly #etw e e n youn g New Zeala n d) #orn 0acific peopl e and their Island) #orn par e n t s and gran d p a r e n t s +owev e r, the differe n t 0acific group s do ten d hav e a co" " o n history of i""igr a tio n and assi "ilation in New Zeala n d 4*inistry of +ealth 19996 0acific people s often hav e a stron g sens e of #elonging to their fa"ilies, the church and the 0acific co" " u ni t y An individu als identity and well#ein g are tradition ally dep e n d e n t on fa"ily herita g e , fa"ily conn e c tion s , roles and respo n si#ilities Althoug h the stre n g t h of "ut u al fa"ily o#ligation s is weak e nin g due to socioeco n o "ic factors and assi"ilation within New Zeala n d societ y, the e&te n d e d fa"ily struct ur e is still at the centr e of 0acific cultur e s , #eh a vio ur s and #eliefs 4*inistry of +ealth 1999? @inau 19856 !hes e social orga nis a tio n s 4fa"ily and church6 provide significant and "e a nin gful relation s hip s that prot e c t "e " # e r s agains t suicide 42esnick et al 1999? @inau 1985, 199;? $kegg 19996, and that ne e d to #e res p e c t e d in dev elo ping suicide prev e n tio n stra t e gi e s and service s *ent al illness is often #eliev e d to #e a result of #re a kin g of tapu 4ta#oo6, usu ally involving offenc e s agains t fa"ily, sup e riors, sacr e d sy"# ols and plac e s !he tradition al healer is usu ally the first pers o n cons ult e d when a 0acific pers o n #eco " e s "e n t ally unw ell $uicide is consid e r e d to #e the ulti"a t e re%ection of ones fa"ily and is sha " e f ul to the fa"ily, esp e ci ally in relation to a fa"ilys sens e of failure to ad e = u a t e l y care for and suppor t the individu al who is ill 4/ath g a t e and 0ulotu) 1nde " a n n 19996 7ther issue s that ne e d to #e consid e r e d in dev elo pin g appro pria t e suicide prev e n tio n stra t e gi e s and service s includ e cycles of social and inter) gen e r a tio n al disadv a n t a g e , poor socioec o n o "ic stat u s , and decline in pare n t al suppor t associa t e d with the disint e g r a tio n of tradition al fa"ily struct u r e s !hes e issue s "a y #e co"p o u n d e d #y "igra tio n, ur#a nis a tio n and the res ult a n t
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loss of social suppor t and significan t interp e r s o n al relation s hip s 4@inau and -asalo 19886 $ervice s for 0acific peopl e re=uir e consid er a tio n of their cultur al cont e & t s and #eliefs 0acific people who are suicidal should #e offere d the input of specialist 0acific "e n t al he alth workers, and their prefer e n c e for involving fa"ily or other supp ort 4eg, church lead e r s , tradition al healer s6 should #e sough t and resp e c t e d -angu a g e #arriers "ay #e an issu e for so" e 0acific people, #ut ens urin g confide n ti ality can #e difficult when interpr e t e r s are use d, due to the s"all siIe of 0acific co" " u ni ti e s and the sha " e ass ocia t e d with suicidal #eh a viour $uicide prev e n tio n service s resp o n siv e to the nee d s of 0acific people "ay #e dev elo p e d de novo or provid e d #y enh a n cin g e&isting "e n t al healt h service s at 0acific he alth units att a c h e d to hos pit als, ,+/ "e n t al health tea " s , and 0acific he alth provid er s
People of Indian desce n t

,eveloping a suicide prev e n tion strat e g y that is cognis a n t of issues relating to people of Indian ethnicity pos es si"ilar challeng e s to thos e that nee d to #e addre s s e d for other culture s @a"ily and religion, in particular, play an i"port a n t role in individu al health and well#eing Indian people in New Zealan d co"e fro" divers e cultures , and suicide prev e n tion strat e gi e s nee d to acknowled g e this diversity and the specific cultural conte& t s and #eliefs ent ailed Indian people consider fa"ily roles and o#ligations to #e of pri"ary i"port a n c e , and thes e priorities nee d to #e acknowled g e d in suicide preve n tion strat e gi e s I""igration and accultur a tion place strains on tradition al fa"ily roles and respo n si#ilities, and on individuals who fail to "e e t thes e roles In particular, Asha " e and Alosing face are powerful construct s , and ways of addr e s sing thes e "att e r s 4#y, for e&a " pl e, various for"s of fa"ily ther a p y6 need to #e taken account of in treat " e n t and "an a g e " e n t practice s for thos e with "en t al health pro#le " s and<or suicidal #eh aviour
Asian population s
Asians constitu t e the faste s t) growing ethnic co" " u nit y in New Zeala n d !hey co"e fro" divers e eth nic, religious and political #ackgro u n d s #ut nev er t h el e s s shar e so" e co" " o n #eliefs and e&p e ri e n c e s Issue s that nee d to #e consid er e d in ens urin g that suicide prev e n tio n stra t e gi e s are appro pria t e for Asians includ e recog nisin g that cultur al value s and #eliefs vary dep e n di n g on the su#cult ur e and the individu als own degr e e of accultur a tio n to 'est e r n value s A"ong .hines e peopl e, suicide is see n as stig " a ti sin g and sha "i n g , #oth to the individu al and to the collective est e e " of the fa"ily !radition al value s disap pr o v e of divulging infor" a tio n that is privat e or sha " e f ul to peopl e outsid e of the fa"ily, let alone to a pers o n of anot h e r cultur e $ervice s for people fro" Asian co" " u ni ti e s who are suicidal or "e n t ally ill should provide options for cultur ally appro pria t e service s -angu a g e #arriers "ay #e a "a%or difficulty for so" e Asians, particularly aroun d the issue of und er s t a n d i n g and discus sin g co"ple & e"o tio n s in 1nglish !here can #e difficulties in o#t aining interpr e t e r s who
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are not known to the pers o n or their fa"ily, and who will not contri#ut e to the pers o ns sens e of sha " e and stig " a ti s a tio n
6efu% e e %roups
*any refug e e s hav e endur e d or witne s s e d so" e sort of physic al or psycholo gic al trau " a 4*inistry of +ealth 5001 a 6 It is esti " a t e d that ;0 perc e n t of refug e e s hav e directly e&p erie n c e d sev er e trau " a .ons e = u e n tl y, they are at incre a s e d risk for physic al and psych ologic al se= u el a e of thes e e&p erie n c e s , including suicidal #eh a viour 7ften refug e e s hav e e&p erie n c e d "ultiple loss e s fa"ily, ho" e , identity, role, langu a g e , cultur e, sens e of self and trust in oth er s 4*inistry of +ealth 5001 a6 A nu "# e r of issu e s ne e d to #e consid e r e d in dev elo pin g suicide prev e n tio n stra t e gi e s that are inclusive of the refug e e popula tion 2efug e e s "ay #e distrus tful of official ag e n ci e s and healt h syst e " s .linical service s nee d to take care to "ak e trans p a r e n t the inten tio n #ehind any action, and the pot e n ti al cons e = u e n c e s for the pers o n If interpr e t e r s are nee d e d , care "us t #e take n over confide n ti ality issu e s #ec a u s e "a n y of the co" " u ni ti e s are s"all and peopl e "ay know each other 2efug e e s with "e n t al health pro#le " s "a y #e referr e d to specialist service s 4eg, 2efug e e s as $urvivors6
Developin % culturall& approp ri a t e suicide preven tio n service s

!here are a nu" # e r of gen e ric and prag " a tic issue s that ne e d to #e addr e s s e d when dev elo ping cultur ally infor" e d suicide prev e n tio n stra t e gi e s 4Institut e of *edicine 5005? C$ ,epart " e n t of +ealth and +u"a n $ervice s 500;6 !hes e are discus s e d #elow !here are no univers ally acce p t e d definitions for suicidal #eh a vio ur, and this issue #eco " e s esp e ci ally challen gin g when "e a s u rin g suicidality in a rang e of cultur e s In particular, res e a r c h and evalu a tio n with cultur ally and linguistically divers e populatio n s rais e pro#le " s of "e a s u r e " e n t e=uivale n c e , det er "i n a ti o n of suicidal inten t, cultur al variation in conc e p t s and langu a g e use d for suicide, and difficulties in conv e yin g co"ple & pers o n al, philosop hic al and cognitive feelings in a differe n t langu a g e @or various cultur al group s a =ualita tiv e res e a r c h appro a c h 4eg, using focus group s 6 "ay assist discus sio n and incre a s e eng a g e " e n t with group s !he use of tele " e dicin e tech n ologie s "a y incre a s e inclusion and particip a tion, particularly of group s in re"o t e are a s for who " service delivery and res e a r c h are pro#le " a t ic A rang e of ethical consid er a tio n s nee d to #e take n into accou n t when conduc tin g res e a r c h with cultur ally divers e group s 3ey conc e p t s includ e resp e c t for the co" " u ni t y, est a #lis hing trust and colla#or a tiv e working
arra n g e " e n t s with the co" " u ni t y, the nee d to dev elo p a tran s p a r e n t cons e n t proce s s taking into accou n t low levels of literac y, and pow er i"#ala n c e s #etw e e n the res e a r c h e r and particip a n t s @or so" e co" " u ni ti e s and so" e studie s it "ay #e nece s s a r y for the res e a r c h e r and co" " u ni t y to %ointly dev elop cons e n t proce d u r e s , stud y ai"s and safeg u a r d s It "a y #e nec e s s a r y to o#t ain co" " u nit y cons e n t as well as individu al cons e n t /eing cognis a n t of cultur al ta#oo s and und e r s t a n di n g the #elief syst e " s surrou n di n g suicidal #eh a viour "a y pro "o t e eng a g e " e n t with cultur ally differe n t co" " u ni ti e s and help to "ini"is e the stig " a that often acco " p a ni e s "e n t al illnes s and suicidal #eh a vio ur in thos e co" " u nitie s .ultur e plays a significant role in suicidality, as shown #y evide n c e that eth nic group s trans p o r t cultur al patt e r n s of suicidal #eh a viour with the " on "igr a tion *igrant s patt e r n s and "et h o d s of suicide "ore closely res e " # l e thos e of their countr y of origin than thos e of the countr y to which they hav e "ov e d $uicide patt e r n s co" e to res e " #l e thos e of the host countr y as succe s siv e gen e r a tio n s #eco " e est a #lis h e d and accultur a t e d 4$ingh and $iahpu s h 5001? +ovey and 3ing 1999? +ovey 5000 a , 5000 #6 @a"ily, cultur al "aint e n a n c e , ethnic den sity and social integr a tio n app e a r to #e prot e c tiv e factors for "os t ethnic group s $piritu al or religious #elief also app e a r s to prot e c t agains t suicide for "a n y eth nic group s , althou g h if a religious group is a "inority the prot e c tiv e effect "ay #e lost -ess accultur a t e d "e " # e r s of ethnic group s in New Zeala n d 4oth er than *ori6 ten d to hav e lower rat e s of usag e of "e n t al healt h service s tha n the gen e r al popula tion ,evelopin g a cultur ally appro pria t e suicide prev e n tio n stra t e g y "ay "e a n inves tin g in i"proving the acce s si#ility and acce p t a #ility of "e n t al health service s for "e " # e r s of other eth nic group s $ervice s could #e i"prov e d #y i"ple " e n ti n g e&isting #lue print s fully, and using "or e langu a g e interpr e t e r s , cultur al interpr e t e r s and eth nic advisors 1thno) specific service s, training "ains tr e a " staff in cross) cultur al issue s , and acknowle d gi n g the clients co" "it " e n t s to spiritu al #eliefs and fa"ily 4wher e appro pria t e 6 are likely to #e #en eficial In particular, >0s nee d to hav e acce s s to interpr e t e r s 4at no cost to the " s el v e s or the patie n t6 to de al with "e n t al he alth issue s *ore gen e r ally, und er s t a n d i n g how cultur e relating to ethnicity can #es t #e incorpor a t e d into suicide prev e n tio n strat e gi e s is a dev elo ping field and a challen g e to #e addr e s s e d in i"ple " e n ti n g such stra t e gi e s
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# Actions to 6educ e and Prev e n t Suicide

In the previou s sections , the epid e "iolog y and ti"e tren d s of suicidal #eh a vio ur in New Zeala n d were su " " a ri s e d and the res e a r c h literat u r e a#ou t risk and prot e c tiv e factors for suicidal #eh a viour was review e d !he "a%or the " e s relev a n t to prev e n ti n g suicide and suicide att e " p t that e" e r g e fro" the s e review s are outline d #elow 4for furth er review s see also Institut e of *edicine 5005? >ould et al 500:? $haffer et al 5001? +awton and van +eering e n 5000? Baco#s et al 500:? +awton et al 5000? *aris et al 50006 Althoug h res e a r c h findings sugg e s t that a rang e of social, pers o n ality, childhoo d and relat e d factors "ak e contri#u tio n s to risks of suicidal #eh a vio ur, #y far the large s t contri#ution co"e s fro" "e n t al healt h pro#le " s , in particular, "oo d disord e r s , previou s suicidal #eh a viour, and "e n t al health pro#le " s !hes e findings i"ply that a "a%or plank of any prag " a t ic, evide n c e) #as e d suicide prev e n tio n stra t e g y "us t involve appro a c h e s that ai" to i"prov e the det e c tion, tre a t " e n t , "a n a g e " e n t and prev e n tio n of thes e disord e r s in the popula tio n !he "os t gen e r al appro a c h is throu g h popula tion) #as e d appro a c h e s that encour a g e positive "e n t al he alth, i"prov e d pu#lic und e r s t a n di n g of "e n t al illnes s, and i"prov e d det e c tion, tre a t " e n t and "a n a g e " e n t of "e n t al disord e r s !wo appro a c h e s "a y #e of particular useF initiative s focusing on the #ett e r recog nition, tre a t " e n t and "a n a g e " e n t of depr e s sio n? and par allel progr a " " e s design e d to addr e s s alcohol and su#s t a n c e ) us e disord e r s Althoug h popula tion) #as e d initiative s "ay reduc e rate s of "e n t al disord e r s within the popula tion, inevita #ly a fraction of the popula tio n will dev elop such disord e r s !his re=uire s the availa#ility of ade = u a t e psychia t ric service s to addr e s s their "e n t al he alth nee d s A the " e that perv a d e s res e a r c h into suicidal #eh a vio ur is that a s"all #ut cons picu o u s group of youn g people vulner a #l e to suicidal #eh a viour s is char a c t e ris e d #y childhoo d histories of social disadv a n t a g e and fa"ily dysfunction !hes e findings sugg e s t that an i"port a n t ste p in reducing the nu "# e r of people who are vulner a #l e to suicidal #eh a viour s is throu g h progr a " " e s that reduc e the nu "# e r of children e&pos e d to uns a tisfa c t or y, disadv a n t a g e d or dysfunc tio n al environ " e n t s that lead to the risk of later suicide att e " p t !here are a nu" # e r of strat e gi e s #y which this targ e t "ight #e achiev e d , including popula tion) #as e d progr a " " e s design e d to reduc e social ine=uity and social discri"in a tio n $uch progr a " " e s "ay "ak e an effective contri#ution to 4esp e ci ally youth6 suicide prev e n tio n #y providing an e=uit a #l e social environ " e n t in which other, "or e targ e t e d , appro a c h e s to suicide prev e n tio n would hav e their #es t chanc e of succe s s Anoth er
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appro a c h focus e s on the dev elop " e n t of gen e r al "e n t al health progr a " " e s , which ai" to foster good "e n t al healt h skills to pro "o t e resiliency and addr e s s the psych o s o ci al nee d s of thos e e&po s e d to stre s s and adv er sity A furth er appro a c h lies in school) #as e d co"p e t e n c y) pro "o tin g and stres s) reducin g progr a " " e s to reduc e the risks of "e n t al disord e r s and #eh a viour s with which suicidal #eh a vio ur is ass ocia t e d A furth e r appro a c h to yout h suicide prev e n tio n lies with the provision of fa"ily suppor t and early interv e n tio n progr a " " e s targ e ti n g at) risk fa"ilies and design e d to a" elior a t e infant and early) childhoo d e&po s u r e to fa"ily disadv a n t a g e and dysfunction, and to opti"is e childhoo d and adoles c e n t educ a tio n al and life opport u nitie s An i"port a n t res e a r c h finding is that youn g people in welfar e care are at incre a s e d risk of suicidal #eh a vio ur co"p a r e d with their peer s who do not acce s s welfar e services A furth er appro a c h to suicide prev e n tio n "a y lie in dev elo ping targ e t e d progr a " " e s to ens ur e youn g people receiving welfare care get ade = u a t e supp ortiv e care and prot ec tion, and appro pria t e "e n t al healt h service s 7ne of the over all purpos e s of a nation al suicide prev e n tio n stra t e g y "us t #e to reduc e ine=u alitie s a"o n g differe n t popula tio n group s 2educing suicidal #eh a viour in *ori yout h should #e a priority for action Accordingly, a nation al strat e g y ne e d s to #e design e d to #e consist e n t with *ori nee d s and e&p e c t a ti o n s , to i"prov e *ori healt h and well#eing and to pro "o t e *ori dev elop " e n t Goung *ori people hav e high er rate s of suicidal #eh a viour tha n their non) *ori peer s and are disprop or tio n a t el y repr e s e n t e d in suicide and suicide att e " p t statis tics !he *ori conc e p t of hauor a is centr al in the lives of "a n y *ori, and a nation al stra t e g y "us t recog nis e that suicide prev e n tio n activities in New Zeala n d "us t #e cognis a n t of this #roa d, holistic view of he alth A "a%or popula tio n) #as e d co"p o n e n t of "a n y nation al suicide prev e n tio n stra t e gi e s focus e s on restricting acce s s to "e a n s of suicide +owev er, the wide availa#ility of the "os t co" " o n "e t h o d s of suicide in New Zeala n d 4han gin g, vehicle e&h a u s t gas6 sugg e s t s that ther e is li"ite d scop e for the restriction of acce s s to "e a n s of suicide to play a su#s t a n ti al role in New Zeala n d suicide prev e n tio n, for youth or for adults Nevert h el e s s , wher e it is possi#le to "ini"is e suicide risk #y restricting acce s s to "et h o d s of suicide, thes e restriction s should #e institut e d as a "a t t e r of res po n si#l e and prud e n t A#est practice *ost young peopl e who die #y suicide are not tee n a g e r s #ut youn g adults age d 50 5; years +owev e r, the "a%ority of thos e who "ak e non) fatal suicide att e " p t s are young 4pre d o "i n a n tl y fe"al e6 tee n a g e r s !his o#s erv a tio n i"plies that youth suicide prev e n tio n progr a " " e s nee d to #e inclusive and dev elo p e d for the entire age rang e of 18 5; years !o dat e, youth suicide progr a " " e s hav e ten d e d to focus on school) #as e d appro a c h e s !here is a dear t h of prev e n tio n progr a " " e s appro p ri a t e for
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youn g "ale s age d 18 5; who hav e left school and who cons titu t e the "a%ority of so) called yout h suicide s Goung peopl e, esp e ci ally "ale s, who are not affiliate d with eith er a work or an educ a tio n al ent e r p ris e and who "ight #e descri# e d as drifting are at incre a s e d risk of suicide and suicide att e " p t !he profile of risk and prot e c tiv e factors in adults is si"ilar in "a n y ways to that for youth !he "a%or e&ce p tion is that childhoo d and fa"ily e&p erie n c e s app e a r to play a less er role in suicidal #eh a viour s #y adults and older people, and, conv er s el y, "e n t al health factors and rece n t life eve n t s e" e r g e as #eing "ore influential !his is particularly evide n t for "ood disord e r s , which play an incre a sin gly significant role in the aetiology of suicide with incre a sin g ag e !he "a%or i"plication of thes e findings is that for adult and particularly older adult popula tion s , prev e n tio n strat e gi e s should focus very stron gly on the det e c tion, tre a t " e n t and "a n a g e " e n t of depr e s sio n and the #ett e r recog nition of the life eve n t, social, fa"ily and relat e d factors that "ay contri#u t e to the dev elop " e n t of depr e s sio n in older adults !he "a%ority 4appro&i " a t e l y 98 perc e n t6 of thos e who die #y suicide hav e cont a c t with pri"ar y) care provid er s in the year prior to their de a t h, and appro&i " a t e l y one) third hav e cont a c t with "e n t al he alth service s In the final "ont h #efore dea t h , al"os t half of suicide victi"s hav e cont a c t with pri"a r y) care provid er s , with rate s of cont a c t higher a"o n g older, co"p a r e d with youn g e r , adults !hes e cont a c t s sugg e s t pri"ar y) care provider s are pot e n ti ally well place d to det e c t and assis t a su#s t a n ti al fraction of thos e with "oo d disord e r s and suicidal #eh a viour s +owev e r, ther e is also a ne e d to i"prov e pu#lic knowled g e and attitu d e s a#ou t "e n t al illnes s, depr e s sio n and tre a t " e n t in order to encour a g e and supp ort help) seekin g #eh a viour s a"o n g thos e adults, predo "i n a n tl y "ale s , who do not pres e n tly go to pri"a r y) care provid er s for "e n t al healt h pro#le " s @or this group ther e is also a nee d to dev elo p altern a tiv e sourc e s of co" " u ni t y) #as e d suppor t !he effective prev e n tio n of suicide will likely re=uir e a "ulti) sector al appro a c h that integr a t e s #oth individu al) level and popula tio n) level progr a " " e s to "ini"is e the circu " s t a n c e s that encour a g e suicidal #eh a vio ur s !he risk factors for suicidal #eh a viour are si"ilar to thos e for a rang e of relat e d adv er s e psycho s o ci al outco " e s !herefor e it is unlikely that significant reduc tio n s in suicide rate s will #e achiev e d withou t corres p o n di n g reduction s in the rate s of depr e s sio n, su#s t a n c e a#us e 4including alcohol a#u s e and cann a #i s dep e n d e n c y6 , and do" e s tic violenc e !he "ulti) factorial nat ur e of suicide i"plies that ther e is a ne e d to dev elop a pu#lic privat e part n e r s hip to addr e s s suicide prev e n tio n, with this part n e r s hip co) ordin a t e d acros s gover n " e n t age n cie s and integr a t e d acros s pu#lic and privat e sectors An appro a c h that addr e s s e s an arra y of pro#le " s with co" " o n risk factors and caus al pathw a ys will hav e a #ett e r chanc e of ens urin g that interv e n tio n and prev e n tio n progr a " " e s #eco " e
#-
e"# e d d e d and institution alis e d acros s a rang e of local, region al and nation al activities than an appro a c h that att e " p t s to focus on suicide as a single social issue $uch part n e r s hip struct ur e s will re=uire ade = u a t e , sust ain e d gover n " e n t and co" " u nit y supp ort and reso urc e s to ens ur e that reduc tio n s in suicide rate s are purs u e d using e"pirically dev elo p e d and well) evalu a t e d progr a " " e s $pecifically, ther e is a nee d to ens ur e sust ain e d funding for suicide res e a r c h and prev e n tio n
Points of effective interve n ti o n

!here is, gen e r ally, li"ite d infor" a tio n a#ou t the efficacy, effective n e s s and cost) effective n e s s of a rang e of suicide prev e n tio n progr a " " e s !he curre n t res e a r c h evide n c e a#ou t risk and prot e c tiv e factors for suicide and suicide att e " p t s , and what app e a r s effective or holds pro "is e of effective n e s s in reducing suicidal #eh a viour, sugg e s t the following specific points of interv e n tio n to reduc e suicide and suicide att e " p t Promo tion of ment al health and ment al health literac &
Inves t " e n t in the dev elop " e n t and evalu a tio n of a rang e of progr a " " e s that seek to chan g e pu#lic attitu d e s to suicide, depr e s sio n and "e n t al healt h pro#le " s a"o n g the gen e r al pu#lic and within the healt h and caring profes sio n s $pecific inves t " e n t in a nation al depr e s sio n awar e n e s s progr a " " e that seeks to enh a n c e the recog nition, tre a t " e n t and effectiv e "a n a g e " e n t of depr e s sio n $pecific inves t " e n t in a progr a " " e that focus e s on heigh t e ni n g pu#lic aw ar e n e s s and recog nition of alcohol) relat e d pro#le " s , and the link #etw e e n alcohol a#us e , depr e s sio n and suicide $pecific inves t " e n t in progr a " " e s that att e " p t to reduc e the nu "# e r of people eng a gin g in the har "ful us e of illicit drugs
4edia reportin %
1ncour a g e " e n t of "ut e d "e di a reportin g of suicide and relat e d eve n t s #y "aint aining, i"ple " e n ti n g and pro " o tin g the use of e&isting "e dia resourc e s
6estrict acces s to mea n s of suicide
Inves t " e n t , wher e appro pria t e , in policies and progr a " " e s that restrict acce s s to pote n ti ally leth al "e a n s of suicide
4inimis e suicide risk in hi%h1 risk population s
Inves t " e n t in i"proving acce s s to "e n t al he alth service s, and ens uring a Achain of care 4or continuity of care6 within such service s for people with "e n t al illnes s e s and<or suicidal #eh a viour
#.
,evelop " e n t of policies and progr a " " e s that i"prov e awar e n e s s , recog nition and tre a t " e n t of psychia tric illnes s, "e n t al distre s s and suicidal ideation and #eh a vio ur in people with physical illness 0rovision of appro pria t e services to a" eliora t e the i"pac t of life crises Inves t " e n t in progr a " " e s that seek to reduc e suicide in young *ori Inves t " e n t in progr a " " e s that seek to reduc e suicide in peopl e of other eth nicities in New Zeala n d, including 0acific and Asian people s , and refug e e and i""igr a n t populatio n s Inves t " e n t in progr a " " e s design e d to dev elop "or e effectiv e coping "ec h a nis " s in a rang e of popula tion group s Inves t " e n t in progr a " " e s that seek to i"prov e a sens e of inclusive n e s s for group s that are alien a t e d and disaffiliate d , including the isolat e d elderly, refug e e s , i""igr a n t s , thos e with "e n t al illnes s and socially alien a t e d youn g "e n Inves t " e n t in policies, service s and progr a " " e s that seek to "ini"is e risk of furth er suicidal #eh a vio ur a"o n g individu als with a history of suicide att e " p t Inves t " e n t in policies and progr a " " e s that seek to addr e s s suicide rate s a"o n g "e n Inves t " e n t in progr a " " e s that suppor t at) risk and pro#le " fa"ilies ,evelop " e n t of policies and progr a " " e s that seek to "ini"is e suicides in prisons and police custo d y cells Inves t " e n t in the dev elop " e n t of policies, service s and progr a " " e s that seek to reduc e suicidal #eh a viour in older adults 0rovision of appro pria t e suppor t and service s for fa"ilies with individu als with "e n t al illnes s and suicidal #eh a viour, including suppor t services for fa"ilies #er e a v e d #y suicide, and fa"ilies with e&p e ri e n c e of a 4non) fatal6 suicide att e " p t
Improv e timeline s s of statistical infor m a ti o n and diss e mi n a ti o n , and fund res e a r c h

Inves t " e n t s to ens ur e i"prov e d and ti"ely statis tical infor" a tio n a#ou t suicide "or#idity and "ort ality Inves t " e n t in res e a r c h a#ou t suicide, suicide prev e n tio n and relat e d issue s , including, as a priority, the syst e " a t i c and appro pria t e evalu a tio n of all suicide prev e n tio n and interv e n tio n progr a " " e s 1valuation of the propo s e d nation al stra t e g y for suicide prev e n tio n Inves t " e n t to ens ur e e&isting and new infor" a tio n al and educ a tio n al guidelin e s for various profes sio n al grou p s are i"ple " e n t e d fully and their effective n e s s is evalu a t e d
#0
1ffective diss e "i n a ti o n of res e a r c h evide n c e a#ou t suicidal #eh a vio ur, and a#ou t the effective n e s s , efficiency and cost effectiv e n e s s of suicide prev e n tio n progr a " " e s
Similarities and differe n c e s in persp e c ti v e s

A series of issue s e" e r g e fro" the review of litera t u r e and fro" consid er a tio n of points of effective interv e n tio n to prev e n t suicidal #eh a vio ur !hes e issue s are outline d #elow 6eco n cilin% the mains tr e a m and socioec o n o m i c pers p e c ti v e s A pot e n ti al tension in the de# a t e a#ou t the aetiology of suicide co"e s fro" the differe n c e #etw e e n "e n t al healt h and psych ologic al pers p e c tiv e s , which e"p h a s i s e "e n t al he alth and pers o n al circu "s t a n c e s as det er "i n a n t s of suicide, co"p a r e d to a sociological pers p e c tiv e , which e"p h a s i s e s "acro s o ci al factors and, not a #ly, socioeco n o "ic disadv a n t a g e , as det er "i n a n t s of suicidal #eh a viour s !he pres e n t report enco " p a s s e s #oth pers p e c tiv e s As not e d , aside fro" a possi#le role of une " pl o y " e n t as a precipita tin g factor in suicide, ther e is no fir" evide n c e linking "acro s o ci al and econo "ic tren d s to chan gin g rat e s of suicidal #eh a vio ur s !hes e consid er a tio n s sugg e s t that, at the pres e n t ti"e, socioec o n o "ic factors should #e see n as playing a relatively "inor role in the aetiology of suicidal #eh a vio ur s At the sa " e ti"e li"itation s in the e&isting evide n c e are such that the pot e n ti al role of socioeco n o "ic factors as det er "i n a n t s of suicide should not #e overlook e d Cultur al and ethnic pers p e c ti v e s A secon d "a%or differe n c e in pers p e c tiv e co" e s fro" the tension #etw e e n a pred o "i n a n tly 'est e r n and scientific pers p e c tiv e of risk and prot e c tiv e factors for suicidal #eh a viour and alter n a tiv e cultur al pers p e c tiv e s !here are, non e t h el e s s , so" e #roa d agre e " e n t s a#ou t the role of aetiological factors and the nee d for service s $pecifically, #oth views recog nis e the pot e n ti al roles of "e n t al health and socioec o n o "ic disadv a n t a g e , and #oth e"p h a s i s e the nee d for service s that are sensitive to, and "e e t the nee d s of, various key popula tion s in New Zeala n d including *ori, 0acific people s , Asian, i""igr a n t and refug e e popula tion s !hes e consid er a tio n s sugg e s t that a nation al suicide prev e n tio n strat e g y ne e d s to #e sufficiently #roa d) #as e d to recog nis e that the sa " e risk factors apply in si"ilar ways in differe n t popula tion s , while at the sa " e ti"e recog nising the ne e d for popula tion) specific interv e n tio n s that "e e t the nee d s of differe n t social and cultur al group s Pers p e c ti v e s on risk and resilienc & 2ecen t popular and policy de# a t e s a#ou t youth suicide in New Zeala n d hav e focus e d on the issu e of risk or resiliency to suicidal #eh a viour +owev er, in contr a s t to the inclusive and co"pr e h e n s iv e fra" e w o rk outline d #y *aste n
#)
and 0owell 4500:6, argu " e n t s in New Zeala n d hav e tend e d to adop t a li"ite d pers p e c tiv e in which risk factor res e a r c h has #e e n denigr a t e d as Aneg a tiv e, and resiliency and stre n g t h s ) #as e d res e a r c h has #ee n acclai" e d as Apositive !he rea s o n s for this e"p h a s i s app e a r to aris e fro" the view that 4a6 risk factor res e a r c h is overly neg a tiv e , and<or 4#6 that solution s to the pro#le " of suicide can #e #es t addr e s s e d #y discov erin g factors that contri#ut e to resiliency to adv er sity !hes e ass u " p ti o n s hav e led to the dev elo p " e n t of a s"all literat u r e that has "a d e stron g clai"s a#ou t the ways in which various factors "a y contri#ut e to resiliency to suicide ,espite the app e al of this litera t u r e in "a n y =uart e r s , the res e a r c h evide n c e on resiliency to suicidal #eh a vio ur is spars e , and ther e is little evide n c e a#ou t clear factors that prot ec t ag ain s t suicide, and few clear and replicat e d esti" a t e s of the e&t e n t of the s e #uffering effects The role of the com m u ni t & In previous New Zeala n d suicide prev e n tio n policy ther e has #e e n a stron g e"p h a s i s on co" " u nit y) #as e d initiative s to addr e s s suicide !his pers p e c tiv e is well e&e " plified #y the Nation al Gouth $uicide 0reve n tio n $trat e g y 4*inistry of Gouth Affairs et al 19986 In this res p e c t New Zeala n d suicide prev e n tio n policy e" e r g e s as #eing atypical, since, intern a tio n ally, ther e is incre a sin g recog nition and focus on the dev elop " e n t of profes sion al and relat e d services !his view is e&e " plified #y the C$ review of evide n c e of caus al factors, prev e n tio n initiative s and a #lueprint for the dev elo p " e n t of effective service s for suicide prev e n tio n 4Institut e of *edicine 50056 A policy issue that clearly re=uire s careful thou g h t relat e s to achieving a #ala nc e #etw e e n pers p e c tiv e s e"p h a s i sin g the role of the co" " u nit y in suicide prev e n tio n, and pers p e c tiv e s focusing on the dev elo p " e n t of effective profes sio n al service s !o dat e, New Zeala n ds policy has #e e n heavily weight e d to the co" " u nit y "od el with a less er inves t " e n t in the are a s of profes sio n ally led service s !hes e policy inves t " e n t s "ay ne e d to #e revisite d in the light of the stron g evide n c e a#ou t the role of "e n t al healt h issu e s in suicide prev e n tio n, the incre a sin g focus on gen e tic and #iological factors in the aetiology of suicidal #eh a vio ur, and the growing inves t " e n t 4in "os t overs e a s countrie s 6 in appro a c h e s to suicide prev e n tio n that centr e on pri"ar y care provider s , "e n t al he alth service s, est a #lis hing Achains of care within such service s for thos e who are suicidal, clinical res e a r c h , and syst e " a t ic and appro p ri a t e evalu a tio n of all suicide prev e n tio n and interv e n tio n progr a " " e s In addition, ther e is a relativ e dear t h of evide n c e a#ou t the effectiv e n e s s of co" " u ni t y) #as e d interv e n tio n s in the are a of suicide prev e n tio n !here is a nee d to ens ur e that e&isting and propo s e d co" " u ni t y) #as e d suicide prev e n tio n progr a " " e s are su#%ect e d to syst e " a t ic and appro pria t e evalu a tio n !hes e consid e r a tio n s sugg e s t that ther e "a y #e a nee d for infor" e d co" " e n t at a nation al level a#ou t suicide prev e n tio n, the nation al strat e g y,
-*
res e a r c h priorities, evalu a tion of prev e n tiv e appro a c h e s and i"ple " e n t a ti o n of #es t practic e guideline s !his ne e d "ight #es t #e addr e s s e d #y crea tin g an e&p e r t advisory #oar d which includ e s nation al and intern a tio n al repr e s e n t a t i o n, and repr e s e n t a t i o n fro" the profes sio n al and service grou p s "os t closely align e d with suicide prev e n tio n in New Zeala n d , while at the sa " e ti"e acknowle d gin g that co" " u nit y group s hav e a role in suicide prev e n tio n activities $triking an appro p ri a t e #alanc e #etw e e n profes sio n al pers p e c tiv e s and co" " u nit y pers p e c tiv e s is likely to #e critical to the succe s s of any nation al suicide prev e n tio n stra t e g y
-1
- Conclusio n s
2ese a r c h evide n c e clearly sugg e s t s that suicide is "ultifactorial and co"ple & .ons e = u e n tl y, ther e see " s to #e a rang e of differe n t popula tio n s and sites for pot e n ti al interv e n tio n s to prev e n t or reduc e suicide !his raise s the issue of how #es t to "ak e decisions a#ou t what typ e s of suicide prev e n tio n progr a " " e s should #e supp ort e d 7ne "e a n s of addr e s sin g this issue is to use the findings fro" risk factor res e a r c h to co"p u t e the popula tion) attri#u t a #l e risk 40A26 4/ruIIi et al 1988? /enichou 19916 !he 0A2 "e a s u r e s the perc e n t a g e reduc tio n in the rate of suicide 4or suicide att e " p t 6 that would occur if 4a6 the risk ratio faithfully descri# e d the caus al relations hip #etw e e n the risk factor and risks of suicide, and 4#6 all su#%ect s were not e&po s e d to the risk factor 43rug et al 50056 A series of studie s has calculat e d 0A2s for a rang e of risk factors for suicidal #eh a vio ur In one of the first studie s to report the 0A2 statis tic, /eau tr ais, Boyce, *ulder et al 4199E6 sugg e s t e d that theF eli"ina tio n of all "e n t al disord e r s consid er e d in the an alysis 4"ood disord e r s , su#s t a n c e use disord e r s , an&iet y disord e r s , antisocial #eh a vio ur s , eatin g disord e r s , and non) affectiv e psych o sis6 would result in a reduc tion of 9E 5 perc e n t in the total nu" # e r of suicide att e " p t s In a further study, the authors esti"a t e d 0A2s for thre e cas e control studies of youth suicidal #eha viour 4/eautr ais 1998 a? $haffer et al 199E? >ould et al 199E, 1998? /rent, 0erper, *oritI, /augh er et al 199:? /eautr ais et al 1998d? /rent, 0erper, *oritI, All"an et al 199:? /rent, Bohnson, et al 199:? /eautr ais et al 1998 a, 1998#6 All thre e studies were consist e n t in gen er a tin g 0A2 statistics that sugg e s t e d that "en t al health factors 4including "ood disord er s, su#s t a n c e) use disorder s, antisocial disorder s, previous suicidal #eh aviour and previous psychiatric care6 "ad e the strong e s t and "ost consist e n t contri#utions to the risk of suicidal #eh a viour An Australian popula tion) #as e d stud y has esti " a t e d that the 0A2s for "ood disord e r s in suicidal ideation and suicide att e " p t were of the order of ;0 perc e n t , i"plying that eli"in a tion of "ood disord e r s would reduc e suicidal idea tio n and suicide att e " p t #y al"o s t half 40irkis et al 50006 $i"ilar findings hav e #e e n report e d #y >oldn e y et al 4500 06 In a popula tion study they found that "a%or depr e s sio n "a d e the large s t contri#ution to the risk of suicidal ideation, with a 0A2 of 89 perc e n t 2ece n tly, findings fro" a nation al regist e r) #as e d nes t e d cas e control study of suicide in ,en " a r k show e d that a history of hos pit alis a tio n for "e n t al disord e r was ass ocia t e d with the high e s t 0A2 4;0 perc e n t 6 4Lin et al 500:6 /y co"p a ris o n, 0A2s for une " pl o y " e n t , having a sickne s s) relat e d a#s e n c e fro" work, #eing in the lowes t inco" e grou p, and #eing on a disa#ility or ag e pen sion were 10 perc e n t or lower
!he pers p e c tiv e provide d #y studie s that hav e esti " a t e d 0A2s sugg e s t s that while a wide rang e of pers o n al, social, fa"ily and relat e d factors "ak e contri#ution s to risks of suicidal #eh a vio ur, #y far the large s t contri#ution s co"e fro" "e n t al healt h "e a s u r e s and, particularly, "e a s u r e s of "oo d disord e r s , previous suicidal #eh a vio ur, "e n t al he alth history, and prior tre a t " e n t !he clear i"plication of thes e results is that the "a%or focus of suicide prev e n tio n efforts should #e direct e d at "ini"ising rate s of psychia tric disord e r s and addr e s si n g the risk factors and life pathw a ys that lead to the s e disord e r s
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Appen dix , $pide mi ol o %ic al Data Sourc e s

!he epid e "iological "at e ri al review e d in this report has #e e n derive d fro" the following dat a sourc e s i Infor" a tio n on nu "# e r s of de a t h s and "e t h o d s of suicide was provide d #y the New Zeala n d +ealth Infor" a tio n $ervice 4NZ+I$6 fro" "ort ality dat a collat e d and pu#lish e d ann u ally #y the *inistry of +ealth for the year s 1980 to 5000 Cnpu#lish e d 5001 "ort ality dat a was provid e d for use in this report #y NZ+I$ to the auth or 4A-/6 ,ata on suicide att e " p t s was provide d to the auth or #y NZ+I$, #ut this has #e e n supple " e n t e d #y "a t e ri al collect e d #y the .ant e r # u r y $uicide 0ro%ect since 1991 Intern a tio n al dat a on tren d s in the use of "e t h o d s for suicide has #e e n o#tain e d fro" pu#lish e d pap e r s and articles 2efer e n c e s are provide d for each of thes e sourc e s
ii
iii
In New Zeala n d , suicide is define d #y a coronial verdict All susp e c t e d suicide dea t h s are inves tig a t e d #y a coron e r who has the pow er to order an auto p s y and gath e r all infor" a tio n nec e s s a r y to reac h a verdict on caus e of dea t h 4,eavoll et al 199:6
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6efer e n c e s
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Suicide Preve n tio n

% 3i5e 3rends and E8ide5iology .................................................../

2 >is1 ?a4tors ...................................................................................2,

& >esilien4y and Prote4ti6e ?a4tors .............................................,& , Cultural *ssues ..............................................................................,.

5 A4tions to >edu4e and Pre6ent Sui4ide ...................................5,

Points o e e4ti6e inter6ention ......................................................................................5Si5ilarities and di eren4es in 8ers8e4ti6es ................................................................5;

Structur e of the report

1 Time Trend s and $pide mi olo % &

Time trend s in 'ew (ealan d suicide rates, 1)#* **

'ote: 2002 data are 8ro6isional.

, 'e( )ealand sui4ide rates, "y se$, %;50 2002

Deaths per 1**,***

'ote: 2002 data are 8ro6isionalF rates are age standardised.

'ote: 2002 data are 8ro6isional.

'ote: 2002 data are 8ro6isional.

4a5or cause s of death

'e( )ealand leading 4auses o death, "y age grou8, 2000

A44idents Can4er Congenital 'er6ous syste5 Sui4ide

Hndeter5ine !eart d disease Congenital 'er6ous syste5

Endo4rine >es8iratory *n e4tious diseases

!eart disease Assault Endo4rine

>es8iratory Sui4ide 'er6ous syste5 Digesti6e syste5 *n e4tious diseases Congenital

Digesti6e syste5 'er6ous syste5 Sui4ide *n e4tious diseases

Digesti6e syste5 Mental disorders A44idents <enitourinary

'er6ous syste5 Digesti6e syste5 Mental disorders Sui4ide

Hndeter5ine 'er6ous d syste5 A >es8iratory

Mus4ulos1eleta Mus4ulos1eleta <enitourinar l l y

Suicide rate s b& ethnicit&

'ote: 2002 data are 8ro6isional.

Intern a ti on al comp aris o n s of suicide rates

A%e1standardised rate 2per 1**,***3

+i%ure 1*, 3otal e5ale sui4ide rates or sele4ted #ECD 4ountries

A%e1standardised rate 2per 1**,***3

A%e1standardised rate 2per 1**,***3

A%e1standardised rate 2per 1**,***3

8ospitalisati on for suicide atte m p t

Trend s in meth o d s of suicide and suicide atte m p t

Population s at hi%h risk for suicide and suicide atte m p t

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4ental health factors

Ps&ch olo%ical risk factors

'eurobiolo%ical risk factors

Childhoo d adve rsit &

S ocial and dem o% r a p h i c factors

Social factors releva n t to suicide preve n tio n in 'ew (ealan d

! 6esilienc & and Protec tiv e +actor s

" Cultur al Issues

People of Indian desce n t

Developin % culturall& approp ri a t e suicide preven tio n service s

# Actions to 6educ e and Prev e n t Suicide

Points of effective interve n ti o n

6estrict acces s to mea n s of suicide

4inimis e suicide risk in hi%h1 risk population s

Improv e timeline s s of statistical infor m a ti o n and diss e mi n a ti o n , and fund res e a r c h

Similarities and differe n c e s in persp e c ti v e s

Appen dix , $pide mi ol o %ic al Data Sourc e s

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Deaths per 1,*

A%e1standardised rate 2per 1,*3

A%e1standardised rate 2per 1,*3

A%e1standardised rate 2per 1,*3

A%e1standardised rate 2per 1,*3