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Negative Life Events, Adverse Life Circumstances and Suicide in New Zealand

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Abstract

A review of literature on the role of negative life events and adverse life circumstances in suicide indicates they better explain the antecedents of suicide than psychiatric disorders.
Negative Life Events, Adverse Life
Circumstances and Suicide in New Zealand
INTRODUCTION
Researchers have noted that “Identification of those at greatest risk for attempting suicide is critical for effective
prevention and intervention efforts.” (Bagge et al, 2012). Data on suicide trends in New Zealand show increases in
suicide rates for a range of age, ethnic and occupational groups suggesting the current medical model of suicide
prevention is ineffective for these groups. This is consistent with a review of the impact on suicide rates of
implementing new mental health policies, programs and legislation in 100 countries which found most mental
health initiatives are associated with an increase in suicide rates” (Burgess & Pirkis, 2004).
The primacy of the medical model of suicide prevention in New Zealand has seen significant resource invested in
identifying individual pathology as a marker of suicide risk while relatively little attention has been paid to
identifying and addressing the role of negative life events and circumstances in suicide. The international literature
on risk factors for suicide consistently identifies a range of negative life events (NLEs) and adverse life
circumstances (ALCs) associated with suicide. Precipitating events have been found in up to 96% of suicides with
studies showing social factors, particularly social isolation confer clear suicide risk (Amatai et al, 2012; Duberstein
et al 2004; DeLeo, 2004; Lester, 1997). Evaluations of suicide prevention programmes based on
sociological/ecological theory have produced significant reductions in suicide rates particularly among youth and
indigenous populations (Kral, 2012; Mullaney et al, 2009). A large study of the links between adverse childhood
events and suicide attempts found the reduction in suicide attempts that would be observed if the population
were entirely unexposed to the adverse events studied was 67%, 64%, and 80% respectively for lifetime, adult, and
childhood/adolescent suicide attempts. (Dube et al, 2001).
Even those who adhere to the theory that suicide is caused by depression and other ‘mental illnesses’ recognize
that the vast majority of those who meet diagnostic criteria will not kill themselves. Given Ministry of Health
estimates that over 50% of Maori and almost 50% of youth will suffer a mental disorder during their lifetime, this
approach lacks precision in identifying those most at risk of suicide and determining whether the risk of suicide for
any individual is chronic or acute. In addition, there is a strong body of evidence pointing to suicide as an iatrogenic
effect of mental health treatment.
Research has consistently shown that NLEs, particularly those involving relationship loss and conflict, precede
many suicides and have a differential impact by gender and age. Joiner’s Interpersonal Psychological Theory of
Suicide suggests these events lead to a desire to die where they undermine a sense of belonging and trigger a
sense of burdensomeness. These relationship crises are however, common life events and their presence alone
does not predict suicidality. According to Joiner’s theory, differentiating those who desire death from those who
are capable of self-inflicted death is exposure to painful and provocative NLEs and ALCs or exposure to
psychoactive substances which desensitize individuals to pain and lower the fear of death.
Coroners files provide a rich source of data from multiple informants on the circumstances and events which lead
to completed suicide. A systematic review of this data could be expected to yield valuable information on the
prevalence and patterns, impact and interactions of factors that precipitate suicide in the New Zealand population.
A shift in suicide prevention policy and practice from a pharmacologically focused mental health approach to a
sociological approach may be effected by robust New Zealand data showing NLEs and ALCs have a stronger causal
association with suicide than depression and other psychiatric disorders. It may also influence Coroners to
conduct a sociological rather than psychological autopsy in suspected suicide cases and to therefore focus on a
broader range of factors in their assessment of the circumstances leading to suicide deaths.
BACKGROUND
Suicide accounts for around 550 deaths per annum in New Zealand. Maori, Youth and Older New Zealanders are
over-represented in the suicide statistics.
Historically, suicide has been seen as a product of a social environment rather than pathology in the ind ividuals
who are its victims. In recent decades however, this understanding of suicide has been displaced as the medical
model, with its emphasis on biological psychiatry, which has dominated research and practice in suicide prevention
and characterizes suicide as a result of individual deficits rather than social influences.
This medicalization of suicide has resulted in largely unchallenged claims that 90% of those who die by suicide do
so as a result of mental illness and that the focus of suicide prevention programmes should be on screening for
psychiatric disorders and engagement in mental health treatment of those who screen positive.
It is notable that acceptance of this theory requires adoption of the view that New Zealand youth are at least twice
as disordered as their counterparts in other developed nations, that Maori are twice as disordered as Pakeha and
that the aged, unemployed and students are more psychiatrically ill than the general population. It also requires
its adherents to ignore the large body of evidence that mass screening for psychiatric disorders has no impact on
suicide rates and that both screening and mental health treatment can cause iatrogenic harm (McMillan et al,
2005; NICE Guidelines, 2005; Thombs et al 2012).
In 2005 a new theory of suicide causality arose from the research of Dr Thomas Joiner. Joiner’s Interpersonal
Psychological Theory of Suicide (IPTS) suggested completed suicide occurs as a result of the convergence of three
factors lack of belonging, a sense of burdensomeness and an acquired capability to overcome the self
preservation instinct and end ones life. Joiner theorises that lack of belongi ng (social alienation) and a sense of
being a burden on others (everyone would be better off without me) give rise to the desire to die while acquired
capability arises from exposure to painful and provocative events which habituate individuals to pain and create a
fearlessness necessary to convert that desire into the action required to complete suicide.
Current Trends in Suicide in New Zealand
In 2012, The Chief Coroner reported a 45% increase on average numbers of suicide deaths of young people aged
15-19 years and a 75% increase in suicides of Maori youth of the same age. The OECD reports that young people in
New Zealand kill themselves at twice the rate of Australian and American youth and five times the rate of young
people in the UK (OECD, 2009). Across all ages, suicide accounts for twice the number of deaths as those from road
traffic crashes in New Zealand.
Figures released by the Chief Coroner in 2012 show an overall increase in suicide rates of 1% in the five years from
2007 2012. Within this figure, Maori suicide rates increased 52% and Pasifika suicides 29%. Suicides of students
increased 43% and the increase in suicides by those who were unemployed was 11%.
In 2006, New Zealand moved from a specific youth suicide prevention strategy to an all ages strategy. This change
in focus was said to recognize that 80% of deaths by suicide involve those over 25. In the six years since this change
was implemented, suicides of those under 25 have increased from 20% to 29% of all suicides.
In 2002 the Ministry reported on the prevalence of ethnic groups in the completed suicide statistics. In the 10
years since that data was published, significant change in the ethnic mix of suicide victims has occurred with a 42%
increase in the proportion of victims who are Maori. The table below shows the changed prevalence for each
ethnic group.
Ethnicity of Suicide Victim
Incr/dec in ethnic group as proportion of total suicides
(%)
Maori
42
Pacific
45
Asian
34
Other
-13
The practice of engaging more of the population in mental health treatment to reduce suicide rates has clearly not
been successful in preventing suicide in New Zealand.
The Mental Health Approach to Suicide in New Zealand
Evidence shows the prevalence of diagnosed mental disorder in suicide victims is subject to widely varying
estimates of between 29% and 88% (Lönnqvist, 2000). Diagnosis most often occurs after rather than before death
using the psychological autopsy methodology which has been found to have serious limitations (Bertolote et al).
Estimates of population mental illness include a substantial proportion of disorders involving alcohol and other
substance abuse, a category many would consider a behavior rather than a psychiatric illness.
The research on which the New Zealand Suicide Prevention and Action Plan are based states that
although a wide range of personal, social, family and related factors make contributions to risks of suicidal
behaviour, by far the largest contributions come from mental health measures; in particular, measures of
mood disorders, previous suicidal behaviour, mental health history and prior treatment. The clear
implication of these results is that the major focus of suicide prevention efforts should be directed at
minimising rates of psychiatric disorders and addressing the risk factors and life pathways that lead to
these disorders (Collings & Beautrais, 2005).
The Suicide Prevention Strategy and Action Plan are very strongly focused on identifying mental disorder and
engaging people in treatment and pay little attention to identifying and addressing the antecedents of the sadness,
anxiety, fear, disturbed sleep and appetite, feelings of worthlessness, rapid mood changes and suicidal thoughts
that make up the indicators for these disorders.
By contrast, the US Surgeon General’s Report on Suicide Prevention gives much greater emphasis to social factors
influencing suicide risk saying
…mental health is only one of many factors that can influence suicide risk. For example, enhancing
connectedness to others has been identified as a strategy for preventing suicidal behav iors and other
problems. Although some people may perceive suicide as the act of a troubled person, it is a complex
outcome that is influenced by many factors. Individual characteristics may be important, but so are
relationships with family, peers, and others, and influences from the broader social, cultural, economic,
and physical environments (U.S. Department of Health and Human Services, 2012).
Given estimates from the Ministry of Health that 50.7% of Maori and 46.6% of youth will experience mental illness
during their lifetime (Oakley Browne, 2006; Baxter, 2008), screening for disorders and engaging those who screen
positive in treatment is likely to capture a large number of at risk persons but provide little specificity in identifying
those likely to complete suicide.
New Zealand Ministry of Health figures show Maori are more likely than other ethnic groups to access specialist
mental health services and that 97.0% of those with depression (the disorder mental health professionals most
commonly associate with suicide) make contact with healthcare professionals (Oakley Browne, 2006). A Ministry
funded research published in 2008 found that
The relative risk of being a client of mental health services in 2004 was 1.2 times higher for Māori than for
non-Māori/non-Pacific people. Māori males aged between 20 and 45 years had the highest rates of
mental health service use, with around 5,000 per 100,000 or 1 in 20 Māori males in these age-groups
being clients of mental health services in 2004 (Baxter, 2008).
The research showed high rates of hospitalization for mental disorders amongst Maori with an overall
hospitalisation rate (658.1 hospitalisations for every 100,000 Māori) which is the equivalent of 1 hospital discharge
for every 150 Māori. Māori aged 25–44 years had the highest hospitalisation rates, followed by those aged 1624.
The author reports that over half (52.9%) of hospitalisations in Māori occurred in 25 to 44 year-olds, and around 1
in 4 (24.7%) hospitalisations were in 15 to 24 year-olds (Baxter, 2008).
The suggestion that suicide is a product of lack of access by mentally disordered individuals to mental health care
is somewhat undermined by these figures. Referral to specialist mental health treatment appears to do little to
protect individuals from suicide and there is international evidence to suggest that the introduction of mental
health initiatives actually increases, rather than decreases suicide rates (Burgess et al, 2004). The authors of a
World Health Organisation funded research report which assessed the impact of mental health programmes on
suicide rates across 100 countries found that
A country’s adoption of a substance use policy in a given year was associated with a decrease in male,
female and total suicide rates in the following year and the years beyond that. By contrast, the
introduction of a mental health policy and mental health legislation was associated with an increase in
male and total suicide rates, and the introduction of a therapeutic drugs policy was associated with an
increase in total suicide rates (Burgess et al, 2004).
Other studies have found more contacts with mental health professionals were associated with higher rates of
suicide attempts (Christiansen & Larsen, 2011).
These findings have been borne out in evidence that mental health strategies aimed at identifying and treating
those with mental disorders have not been successful in reducing suicide rates in New Zealand. In particular this
approach has failed to reduce the rates of youth suicide and of Maori suicide. Statistics published by the Minsitry
of Health show the number of New Zealanders becoming clients of mental health services in the period 2002-2007
increased 11.3%. The number of Maori becoming clients increased 22.5%. Youth involvement with mental health
services amongst those in the 15-19 year age group during that period increased 35% across ethnic groups and
48% for Maori 15-19 year olds (Ministry of Health, 2012).
Suicide and Negative Life Events
A more recent theory of suicide, Joiner’s Interpersonal Psychological Theory of Suicide, posits that suicide is a
product of the desire to die arising from lack of belonging and perceived burdensomeness coupled with an
acquired capability to overcome the fear of death. Acquired capability arises from either a lifetime of painful
experiences or use of mind altering substances. This theory returns emphasis to the role environmental factors and
negative life events, rather than individual pathology, play in suicide. It suggests that identification and alteration
of these factors can prevent suicide as can restricting access to psycho-active substances and preventing child
abuse, domestic violence, physical injuries and other painful experiences.
Rather than attributing the increase in completed suicide in certain populations to increased prevalence of mental
illness or unmet need for mental health treatment, this theory suggests that the incidence and/or impact of
negative life events has increased for youth, Maori and women in NZ.
Recent research suggests thwarted belongingness and perceived burdensomeness are the most proximal mental
states that precede the development of thoughts of suicide with stressful life events, mental disorders, and other
risk factors being relatively more distal risk factors. The authors consider assessing for thwarted belongingness and
perceived burdensomeness as important to suicide prevention given they are dynamic and amenable to
therapeutic change (Van Orden et al, 2012).
This theory suggests high suicide rates amongst Maori, youth and the aged arise from higher rates amongst these
groups of social alienation, not having ones contribution valued and experiencing negative life events rather than
suggesting these groups are more mentally disordered than others.
Joiner ascribes the drop in suicide rates during times of celebration (when people pull together to celebrate; and
during times of hardship or tragedy as being a result of people ‘pulling together’ either to celebrate or
commiserate (Joiner, Hollar, & Van Orden, 2006). It is likely this more accurately reflects the lowering of suicide
rates during the Christchurch earthquake and 2011 Rugby World Cup, than does a drop in rates of depression or
substance abuse.
In Joiner’s view
If you think you belong or that you are contributing, you are going to be protected from suicide no matter
what else is going on. Part of the tragedy of suicide is that, unlike other conditions, it’s often just a
perception, one that is correctible through the right kinds of treatment.
Given the low rates of cure for mental disorders and the ability governments, communities and families have to
influence the belongingness and burdensomeness of groups and individuals, Joiners model provides far greater
hope for the prevention of suicide than the mental health model. Joiner’s model provides a framework in which to
understand the impact of NLEs on completed suicide.
LITERATURE REVIEW
A strong body of evidence supports the association between negative life events (NLEs) and suicide attempts with
a smaller number of studies investigating NLEs and completed suicide. Research also shows adverse life
circumstances (ALCs) are associated with suicide.
Negative Life Events
Studies show that in the year before death, suicide completers were more likely than others to have experienced
a range of negative life events including interpersonal conflict (Overholser, 2012; Grimbaldeston, 1999), disruption
of a romantic attachment (Hunt, 2013;), legal or disciplinary problems (Webb, 2011; Grimbaldeston, 1999),
physical illness (U.S. Department of Health and Human Services, 2012), bereavement (Grimbaldeston, 1999),
psychiatric hospitalization (Didham et al, 2006), recent discharge from a psychiatric facility (Cavanagh, 1999;) and
contact with mental health services (Mock, 1996) , being sentenced to psychiatric care (Webb, 2011) bullying
(Cooper, 2012; Brunstein, 2010), unemployment (Grimbaldeston, 1999), poverty, debt (Wong, 2010;), separation
from children (Cooper, 2012;), job problems and residence change (Brent, 1993; Cavanagh, 1993; Heikkinen, 1995;
Cavanagh 1999; Cooper, 2011; Cooper, 2012; Scourfield, 2012 ).
The prevalence of negative life events in a 3 month period preceding suicide, were studied in a nationwide suicide
population (N = 1,067) in Finland which found such events occurring in 80% of suicides. The most commonly
occurring NLEs were Job problems (28%), family discord (23%), somatic illness (22%), financial trouble (18%),
unemployment (16%), separation (14%), death (13%) and illness in family (12%). A study involving adolescent
suicide victims found NLEs in the month before suicide in 70% of cases.
There is evidence that various categories of NLE’s may be differentially associated with suicidal behavior with
problems with romantic relationships and contact with the criminal justice system most commonly preceding
completed suicide (Bragge, 2012; Yen, 2005; Cooper, Appleby, and Amos, 2002) and medically serious suicide
attempts (Beautrais, 1997). A recent study showed the prevalence and impact of relationship loss and conflict on
suicidal behavior applied equally to both men and women.
Other NLEs found to have strong associations with completed suicide include recent separation and bereavement,
and financial and relationship difficulties (Grimdaldston, 1995)
Suicide Attempt and Suicide Risk
Much of the literature on suicide risk identifies previous suicide attempts as a significant predictor of completed
suicide. There is however a body of literature that suggests that attempters and completers are different
populations with different characteristics (Johnson, 2009). The difference in completed suicide rates and attempts,
and particularly in rates by age and gender, may suggest that suicide attempts are different in kind from
completed suicide.
A study of 70 Australian suicides found previous suicide attempts present in 28% of cases with significant behavior
changes or verbalization of the intent to suicide a stronger indicator, preceding 32% of suicides. (Thacore, 2000).
Somatic Illness and Suicide Risk
Some medical conditions, including cancer and chronic diseases that impair physical function and/or lead to
chronic pain, also may increase the risk for suicidal behaviors. Amongst those physical health issues for which
there is evidence of increased suicide risk are cancer, huntington disease, multiple sclerosis, parkinsons disease,
spinal cord injury, traumatic brain injury, epilepsy, migraine, HIV/AIDS, chronic kidney disease, arthritis and
asthma. Many of the drugs used to treat these conditions have been found to increase suicide risk raising the
possibility that it is treatment rather than the disease being treated that is linked with suicide.
Gender and NLEs
Studies have found gender differences in the prevalence of NLEs preceding suicide. Males have been found to be
more likely to have experienced an NLE and to have a higher mean number of NLEs than females with, separation,
financial trouble, job problems and unemployment being more common among males.
Age and NLEs
Studies have found age-related patterns of NLEs preceding suicide with separation, serious family arguments,
financial trouble, job problems, unemployment, and residence change being more common among younger
victims, and somatic illness and retirement more common among older victims. The mean number of NLEs has
shown a tendency to decline with increasing age.
A 1992 study of Australian coroner's records involving 136 suicides in three different ages bands found that across
ages, disruption of interpersonal relationships (boy-girlfriend, de facto, marital, family) was the predominant
stressor preceding the suicide. Compared with the older age group the following) 15-19 year old victims were
more likely to be unemployed and have had legal or disciplinary problems, while those aged 20-24 years were
more likely to have abused drugs and unemployed.
Within the male population younger men are more likely to have experienced job -related NLEs, while older men
are more likely to have been affected by a somatic illness. Somatic illness appeared to be the most important
stressor in elderly suicides, particularly for men. While some studies have found that living alone is a risk factor for
suicide (Grimbaldeston, 1999;), others have found that living alone and diminished opportunity for social
interaction were not common factors in late-life suicides (Heikkinen, 1995).
Many studies indicate an association between negative life events and alcohol misuse with findings that
separation, serious family arguments, financial trouble and unemployment are particularly related to alcohol
misuse. (Fernandez, 2005; Singh, 2008; Heikkinen, 1995).
Adverse Life Circumstances
A number of adverse life experiences have been linked with increased risk of completed suicide. The association
between adverse life circumstances including poverty, economic recession, and unemployment is well established
internationally, but little New Zealand data has been gathered.
New Zealand suicide statistics however show completed suicide rates are highest in the most deprived areas of the
country suggesting an association with low income, poor or overcrowded housing, and lack of access to healthcare.
Congdon however found that it is not deprivation per se that accounts for higher rates of suicide in more deprived
areas but social capital, individual socio-economic status and social isolation which are linked to suicide and that
while all three have approximately equivalent impacts for males, for females social capital exerts a more significant
influence on suicide risk than the two other constructs (Congdon, 2012) .
Those adverse life cirumstances most strongly associated with suicide include unemployment (Burvill, 1992; Milner
et al, 2013; Ceccherini-Nelli & Priebe, 2013; Lundin et al, 2012; Barr et al 2012; Reeves et al, 2012 Kentikelenis et
al,2011, Stuckler et al, 2011), social isolation (Congdon, 2012; Zaheer et al, 2012; Dorling & Gunnell, 2003) , socio-
economic status (Page et al, 2006; Congdon, 2012; Shah et al, 2009) and concerns about job prospects (Almasi et
al, 2009).
Figures provided by New Zealand’s Chief Coroner show that being in prison and being a student confer a higher
risk of suicide. The Canterbury Suicide Project found low income and lack of formal educational qualifications to be
risk factors for completed suicide (Beautrais, 2001; Beautrais, 2003).
Temporality
The literature on suicide attempts shows that individuals are at increased odds of attempting suicide soon after
experiencing a NLE and that suicide following quickly from a negative life event is particularly prevalent for
interpersonal NLEs, especially those involving a romantic partner (Bagge et al, 2012).
Studies of adolescent suicides have found that 70% of suicide completers experienced a NLE in the week prior to
their suicide (Heikkinen et al. 1997) and that almost half the NLEs precipitating suicide occurred during the 24
hours before death (Marttunen, 1993).
New Zealand researchers Beautrais and Collings claim that “At present the single most important known proximal
risk factor for suicide is mental illness (especially depression and substance abuse).” It is possible however that this
view is colored by a lack of New Zealand research examining the prevalence, role and impact of NLEs on completed
suicide and a plethora of research on mental illness as an antecedent of suicide.
The last comprehensive review of NLEs and completed suicide in New Zealand was a review of Coroner’s files for
suicide deaths in 1981 (Antoniadis, 1988). It showed 60% of those who died by suicide experiencing relationship
problems, 40% suffering other life stressors including school or work problems and financial pressures, 28% having
a serious physical illness and 27% having a diagnosis of depression. The majority had had recent contact with the
healthcare professional with 47% having seen such a professional less than four weeks before their death, 31% in
the week before they died and 18% within 24 hours of their suicide.
Psychotropic Drugs & Suicide
There is strong evidence that psychotropic drugs can induce suicidal thinking and behavior in those who use them.
The evidence is sufficiently compelling that the FDA issued a black box warning, their highest warning of lethality,
in 2004 alerting prescribers and patients of the risk of suicidality associated with these drugs.
In addition to suicidal thinking and behavior, there is also evidence that psychotropic drugs can cause completed
suicide and that while this risk may be stronger in those under 24 years of age, it also applies to those over the age
of 24. The following table provides a summary of completed suicides and suicide attempts from adult clinical trials
as produced by the Expert Working Group on the Safety of Selective Serotonin Reuptake Antidepressants 2004
(Healy, 2009).
Psychiatrist and psycho-pharmacologist, Professor David Healy, has recently published a list of prescription drugs
that “companies are obliged to state can cause suicide or for which there is convincing evidence that they have in
fact caused suicide “ (Healy, 2013).
Class
Ingredient Name
Trade Name
Anti-Infectives
Mefloquine
Lariam
Doxycyline
Doryx
D-cycloserine
Seromycin
Fluoroquinolones
Levaquin, Cipro
Oseltamivir
Tamiflu
Contraceptives
Drospirenone
Yasmin
Drospirenone
Yaz
Cyproterone and ethinyl estradiol
Dianette
Anti-Smoking
Varenicline
Chantix
Champix
Buproprion
Zyban
Anti-Asthma
Montelukast
Singulair
Roflumilast
Daxas
Zafirlukast
Accolate
Anti Acne
Isotretinoin
Roaccutane
Doxycycline
Doryx
Antihistamines
Diphenhydramine
Benadryl, Sominex
Chlorphenamine
Chlortimeton
Cyproheptadine
Periactin
Urinary Drugs
Duloxetine
Yentreve
Tamsulosin
Flomax
Finasteride
Propecia
Dutasteride
Avodart
Anti-Nausea
Prochlorperazine
Stemetil, Compro
Metoclopramide
Maxolon, Reglan
Antihypertensives
Clonidine
Catapres
Doxazosin
Cardura
Guanabenz
Wytensin
Guanfacine
Tenex
Hydralazine
Apresoline
Methyldopa
Aldomet, Aldoril, Dopamet
Prazosin
Minipress
Statins
Atorvastatin
Lipitor
Fluvastatin
Lescol
Lovastatin
Mevacor
Mevastatin
Compactin
Pravastatin
Pravachol
Rosuvastatin
Crestor
Simvastatin
Zocor
Stimulants
Methylphenidate
Ritalin
Focalin
Metadate
Concerta
Amphetamine
Dexedrine
Adderall
Vyvanse
Benzodiazepines
Lorazepam
Ativan
Diazepam
Valium
Alprazolam
Xanax
Chlordiazepoxide
Librium
Bromazepam
Lexotan
Oxazepam
Serenid, Serax
Cloabazam
Frisium
Medazepam
Nobrium
Clorazepate
Tranxene
Clonazepam
Klonopin
Antidepressants
Citalopram
Cipramil, Celexa
Escitalopram
Cipralex, Lexapro
Duloxetine
Cymbalta
Fluvoxamine
Luvox, Faverin
Fluoxetine
Prozac
Paroxetine
Paxil, Seroxat, Deroxat, Aropax
Sertraline
Zoloft
Venlafaxine
Effexor
Desvenlafaxine
Pristiq
Mirtazapine
Remeron
Trazodone
Desyrel
Buproprion
Wellbutrin, Zyban
Amitriptyline
Tryptizol, Elavil
Imipramine
Tofranil
Nortriptyline
Allegron, Aventyl
Desipramine
Pertrofran, Norpramin
Clomipramine
Anafranil
Dosulepin
Prothiaden
Lofepramine
Gamanil
Doxepin
Sinequan
Trimipramine
Surmontil
Anticonvulsants
Phenytoin
Epanutin
Sodium Valproate
Epilim, Depakene
Divalproex
Depakote
Carbamazepine
Tegretol
Oxcarbazapine
Trileptal
Lamotrigine
Lamictal
Gabapenin
Neurontin
Pregabalin
Lyrica
Leviracetam
Keppra
Topiramate
Topamax
Tiagabine
Gabitril
Felbamate
Felbatol
Antipsychotics
Chlorpromazine
Thorazine, Largactil
Perphenazine
Fentazine
Trifluoperazine
Stelazine
Haloperidol
Haldol
Flupenthixol
Fluanxol
Pericyazine
Neulactil
Sulpiride
Sulpitil
Molindone
Moban
Aripiprazole
Abilify
Olanzapine
Zyprexa
Risperidone
Riserpdal
Ziprasidone
Geodon
Quetiapine
Seroquel
Paliperidone
Invega
Zotepine
Zoleptil
Iloperidone
Fanapt
Amisulpiride
Solian
Tetrabenazine
Xenazine
In New Zealand, a large observational study undertaken by the Ministry of Health in 2007 found a direct causal link
between increased antidepressant prescribing and hospitalization for serious self-harm (Ministry of Health, 2007).
This finding is consistent with a similar study in the UK (Clayton et al 2000). Neither the Ministry of Health study
nor a previous New Zealand study investigating links between self-harm and completed suicide and SSRI use
(Didham et al, 2005)found an association between SSRI prescribing and completed suicide. These findings provide
poor evidence however given how seriously underpowered they were to detect such a link. The 2005 study for
example included 26 completed suicides but the authors advise that “to determine if there is a doubling of the risk
of suicide would require a sample size of 192, 436 in each treatment group.” A study of New Zealand suicide
victims published by two of the same authors in the following year found “Sedatives, anxiolytics, and
antidepressants were associated with suicide, with the strongest association being for sedatives” (Didham et al,
2006).
A large study, conducted in 2006 involved 1,329 completed suicides and found an increased risk of suicide in the
first month of SSRI use compared to other antidepressant use and that violent suicides were more common in the
SSRI group (Juurlink et al, 2006). A systematic review of studies involving more than 200,000 patients found SSRIs
increased the risk of completed or attempted suicide among adolescents but not adults (Barbui, 2009). A
Cochrane Review of studies comparing SSRI and placebo in children and adolescents found “There was evidence of
an increased risk (58%) of suicide-related outcomes for those on antidepressants compared with a placebo.”
The New Zealand Coroners Court does not collect data on the use of prescription drugs by suicide victims pr ior to
their deaths.
Data on the prescription drug use of New Zealanders who died from suicide under the care of mental health
services between 2007 and 2010 showed 89% of those who died had been prescribed a psychotropic drug in the
six months prior to their suicide. The number of drugs prescribed ranged from 1 to 15 with poly-drug treatment
common amongst suicide victims.
While one might expect diagnosis to be a precondition of prescribing, particularly prescribing multiple drugs, the
data shows 8% of those who were medicated had no diagnosis of a psychiatric disorder.
020 40 60 80 100
1 or more drugs
2 or more drugs
3 or more drugs
4 or more drugs
5 or more drugs
6 or more drugs
Polydrug Use in DHB Medicated Suicide
Victims
2007-2010
The following graph shows the diagnoses of those who died by suicide under the care of DHBs. Despite claims that
depression underlies most suicide, only 42% of those who died by suicide were diagnosed with depression while
89% were medicated.
42
16 13 9 9 7 7 7 5
18
0
5
10
15
20
25
30
35
40
45
All Suicides under DHB Care by Diagnosis
2007-2010
Of the 8% whose records showed no diagnosis of a mental disorder, 50% were medicated with 19% on two drugs
and 13% on 5 drugs.
Domestic Violence, Child Abuse & Suicide
A large body of evidence associates child maltreatment and suicidal thinking, planning and attempts (Gilad et al,
2012; Turner et al, 2012; Rhodes et al, 2012, Christoffersen, 2013). Studies show boys and girls at equal risk (Gilad
et al, 2012). Studies have found that not only abuse, but fear of abuse is associated with suicidality (Mota, 2013)
and that fear of being a victim of violent crime is particularly associated with suicide in young men (Innamorati et
al, 2010).
A range of studies have found intimate partner violence and childhood sexual abuse are strong and consistent risk
factors for suicide attempts in women (Devries et al, 2011; Madal & Zalewska, 2012; Gold et al, 2012 Sansone &
Wiederman, 2007) as is having a mother who had experienced intimate partner violence (Devries et al, 2011).
Emotional or psychological partner violence have been found to predict suicidal ideation in women (Pico-Alfonso
et al, 2006) and in youth (Iwalani et al, 2009)
Studies have found dating violence is associated with suicide planning and suicide attempts in adolescents
(Belshaw et al, 2012) and that violence toward partners is prevalent in men who die from suicide (Connor et al,
2000; Sumaraweera et al, 2008).
Alcohol Abuse & Suicide.
Studies show strong and consistent associations between alcohol misuse and suicidal behaviours including
completed suicide (Branas et al, 2011; Kerr et al, 2011)
The association between binge drinking in young people, particularly pre-teens and early adolescents, and
suicidality is supported by a large body of international evidence (Aseltine et al., 2009; Miller et al., 2007; Swahn,
Bossarte, & Sullivent, 2008; Waldrop et al., 2007; and surveys of New Zealand youth (Fleming et al, 2007).
One study examining age-specific associations between heavy episodic drinking and self-reported suicide attempts
in a diverse group of 32,217 students, between the ages of 11 and 19 years, found binge drinking was significantly
associated with self-reported suicide attempts independent of depressive symptoms. It found substantial age
variability in this association, with those aged 13 years and younger, who reported an episode of binge drinking in
the past year, 2.6 times more likely to report an attempt than those who did not report binging in the past year. By
contrast in youths aged 18 years and older reports of suicide attempts were to 1.2 times more likely amongst binge
drinkers and those who did not engage in this behavior (Aseltine et al., 2009).
The conceptualization of alcohol abuse as a mental disorder rather than a social and behavioural issue has served
to focus attempts to reduce alcohol related suicidality on mental health treatment rather than reform of alcohol
policy.
Bullying & Suicide
Recent studies have shown an association between bullying and suicide (Klomek et al, 2008; Pranjić &
Bajraktarević , 2010) with studies showing a more direct association between bullying and completed suicide for
girls than boys ( Klomek at al, 2009). Studies consistently show that both those who perpetrate bullying or are both
victims and bullies and those who are victims experience suicidality (Hinduja & Patchin, 2010; Young Shin, 2009), a
review of 37 studies showed a consistent link between any involvement in bullying and suicide (Young Shin &
Bennett, 2008).
More recently, the role of cyberbullying in suicide has been examined with studies finding a positive association
(Bauman et al, 2013; Hinduja & Patchin, 2010) but not that cyberbullying had a significantly higher risk of suicide
attempt than traditional bullying (Hinduja & Patchin, 2010).
A study of Asian and Pasifika youth found that those who had considered, planned, and attempted suicide had an
elevated incidence of having been a victim of anger/emotional abuse, being intimidated, threatened, sexually
coerced, isolated/excluded, and experiencing peer pressure and physical violence(Iwalani et al, 2009).
CONCLUSION
New Zealand appears to be making little headway in the prevention of suicide particularly for youth, the aged and
Maori. There is significant evidence that our current medical approach to suicide prevention, with its heavy focus
on pharmacology increases suicide risk. Obtaining data on the causal association between Negative Life Events and
Adverse Life Circumstances and suicide in New Zealand through a review of Coroners files may assist with
influencing a change in suicide prevention policy and practice both within the Ministry of Health and the Coroners
Court. Evidence suggests that this in turn may reverse the current trend in suicide in New Zealand.
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Background Depression, isolation, low self-esteem, and lack of hope are just a few of the characteristics evident in adolescents involved in bullying. The aims of this study are as follows: to examine the association between involvement in school bullying and depressive symptoms and suicide ideation among victims, bully victims, and those uninvolved; to investigate the effects of vulnerability factors on depression and suicide ideation among subjects aged 17 involved in school bullying.Methods A self-reported school-based survey was completed by 290 secondary school students aged 17 years, attending the third grade, coming from 15 different classes of secondary schools in the Tuzla (coming from each municipality in the Tuzla Canton), 2007. Using peer nominations, three groups were established: victims, bully victims, and uninvolved participants as control group subjects. Data were obtained using a self-rated questionnaire on bullying, Beck inventory to identify depression and suicide ideations, and state-trait anxiety scales to assess anxiety state/trait among examinees. Data analysis was performed using SPSS version 12.0.Results There was an increased prevalence of depression (29.0% versus 8.8%) and suicidal ideation (16.1% versus 3.5%) in adolescents who have been victims in relationships to respondents who were uninvolved subjects. There was an increased prevalence of depression (17.5% versus 8.8%) and suicidal ideation (15.8.1% versus 3.5%) in adolescents who have been bully victims in relationships to respondents who were uninvolved subjects too. Adolescents who are victims and those who are bully victims are more likely to have suicide ideation compared to uninvolved subjects. Discontent with financial situation is a vulnerability factor associated with elevated levels of depression in victims.Conclusion In evaluations of students involved in bullying behavior, it is important to assess depression and suicide ideation.
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Background: Socio-economic status and income inequality influences cross-national variations in elderly suicide rates. Methods: Data from an earlier study were re-analysed using multiple linear regression to identify independent predictors of elderly suicide rates in males and females in the age-hands 65-74 years and 75 +years. This was considered necessary because the correlates of suicide rates including (i) measures of socio-economic status [per capita gross national domestic product (GDP)] and income inequality (the Gini coeffecient), (ii) measures the quality and quantity of available healthcare services (the proportion of GDP spent on health, per capita expenditure on health and child mortality rates), and (iii) life expectancy were all inter-correlated. Results: The Gini coefficient was the only significant independent predictor of suicide rates in all the four groups (i.e. males and females in the age-bands of 65-74 years and 75+years). Conclusion: This independent association between elderly suicide rates and income inequality, as measured by the Gini coefficient, provided support for the previously proposed aetiological hypothesis with a five sequential stage model. However, there may also be other pathways, in addition to the five sequential stage model, independently influencing elderly suicide rates.
Article
Background It is not clear if the frequency of deliberate self-harm (DSH) is the same in patients taking different pharmacological classes of antidepressant drugs. Aims To compare the frequency of DSH in patients who had been prescribed a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) prior to the DSH event. Method This was a prospective study in 2776 consecutive DSH cases attending an accident and emergency department. The incidence of DSH in TCA-treated cases and SSRI-treated cases is expressed as number of DSH events per 10 000 prescriptions of each antidepressant. Results Significantly more DSH events occurred following the prescription of an SSRI than that of a TCA (P <0.001). The occurrence of DSH was highest with fluoxetine and lowest with amitriptyline. Conclusions Merely prescribing safer-in-overdose antidepressants is unlikely to reduce the overall morbidity from DSH.
This is a systematic study of the social background of Danish males convicted for the first time of lethal violence, either actual or potential (e.g. unlawful killers, attempted homicides, negligent homicide, grievous bodily harm, n = 125). Using registers, the paper addresses the following question: Do young men, convicted of a lethal violent crime (either actual or potential), have the same kind of risk factors related to social disadvantage as other first‐time convicted violent offenders (n = 1,849) and first‐time attempted suicides or completed suicides (n = 476)? The paper describes three separate analyses of the total 1966 birth cohort followed through a 13‐year period from age 15 to 27 (n = 43,403). In each case the discrete‐time Cox model is used to analyse associations between the relatively rare response events and the relatively rare stress factors. Results suggest that all three groups of subjects have a similar exposure to risk conditions, but also that there are important differences in the predictors for the three groups when the risk factors are analysed one by one. So, for example, the experience of domestic violence during adolescence is a strong predictor of males' later violent behaviour but a less strong predictor of suicidal behaviour. In contrast, being battered and being neglected during childhood more strongly predict later suicidal behaviour than violent behaviour. The implications for prevention are considered.
Article
Evidence from European countries indicates a significant rise in suicides from the economic recession, totalling more than 1000 excess deaths in the UK alone. Among the worst affected economies in Europe, such as Greece, suicides have risen by more than 60% since 2007.2 Thus far, there has been little or no analysis of US mental health data, mostly owing to delays in data availability. Here, we extend our previous analyses of recessions and suicides in Europe to assess trends in all 50 US states. We use data on suicide mortality rates from 1999 to 2010 from the Centers for Disease Control and Prevention. Unemployment data come from the Bureau of Labor Statistics. Time-trend regression models were used to assess excess suicides occurring during the economic crisis -- ie, deaths over and above the level that would be expected if historical trends continued (see appendix for methodological details). Although there are concerns that suicide data are under-reported in the USA, these biases are likely to have been consistent over this relatively short period, although they might lead to a conservative estimate of the mental health effects of the crisis. Looking across US states between 1999 and 2010, we found that the strongest correlation between unemployment and suicides was in Texas (r=0·91), but overall the correlations were statistically indistinguishable between the north, south, east, and west, or when disaggregating states by Democrat and Republican governors (appendix). Small numbers of suicides in small populations limit a state-by-state comparison for all 50 states. Similar patterns were seen if absolute numbers of suicides were used instead of overall rates. Suicide is a rare outcome of mental illness; these data are likely to be the most visible indicator of major depression and anxiety disorders, as seen in primary-care settings in Spain and in the Greek population. The pattern of accelerating suicides noted in the USA mirrors that recorded for economic reasons in Italy. Future research should explore other risk factors such as foreclosures and job and income losses, and modifying factors such as gun control policies, access to the means of self-harm, and vulnerable groups, which could explain the remaining portion of the suicide rise observed during the recession. Our findings have immediate implications for policy. Given that some countries have avoided increases in suicides despite significant economic downturns, there is a clear need to implement policy initiatives that promote the resilience of populations during the ongoing recession. Active labour market programs--projects that immediately help the unemployed find social support and new work opportunities (even part time)--and mental health prevention programs seem to mitigate significantly the negative mental health effects of recessions. The fact that countries such as Sweden have been able to prevent suicide rises despite major recessions reveals opportunities to protect Americans from further risks of suicide during the continued economic downturn. Language: en