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Suicides among men aged 35-64 years increased by 27% between 1999 and 2013, yet little research exists to examine the nature of the suicide risk within this population. Many men do not seek help if they have mental health problems and suicides may occur in reaction to stressful circumstances. We examined the precipitating circumstances of 600 suicides without known mental health or substance abuse (MH/SA) problems and with a recent crisis. Whether these suicides occurred within the context of an acute crisis only or in the context of chronic circumstances was observed. Using data from the National Violent Death Reporting System and employing mixed-methods analysis, we examined the circumstances and context of a census of middle-aged male suicides (n = 600) in seven states between 2005 and 2010. Precipitating circumstances among this group involved intimate partner problems (IPP; 58.3%), criminal/legal problems (50.7%), job/financial problems (22.5%), and health problems (13.5%). Men with IPP and criminal/legal issues were more likely than men with health and/or job/financial issues to experience suicide in the context of an acute crisis only. Suicides occurring in reaction to an acute crisis only or in the context of acute and chronic circumstances lend themselves to opportunities for intervention. Further implications are discussed.
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Crisis: The Journal of Crisis Intervention and
Suicide Prevention
Acute and Chronic Risk Preceding Suicidal Crises Among
Middle-Aged Men Without Known Mental Health and/or
Substance Abuse Problems: An Exploratory
Mixed-Methods Analysis
Lara B. Schiff, Kristin M. Holland, Deborah M. Stone, J. Logan, Khiya J. Marshall, Brandi
Martell, and Brad Bartholow
Online First Publication, June 30, 2015.
Schiff, L. B., Holland, K. M., Stone, D. M., Logan, J., Marshall, K. J., Martell, B., & Bartholow, B.
(2015, June 30). Acute and Chronic Risk Preceding Suicidal Crises Among Middle-Aged Men
Without Known Mental Health and/or Substance Abuse Problems: An Exploratory
Mixed-Methods Analysis. Crisis: The Journal of Crisis Intervention and Suicide Prevention.
Advance online publication.
© 2015 Hogrefe Publishing Crisis 2015
DOI: 10.1027/0227-5910/a000329
Research Trends
Acute and Chronic Risk Preceding
Suicidal Crises Among Middle-Aged
Men Without Known Mental Health
and/or Substance Abuse Problems
An Exploratory Mixed-Methods Analysis
Lara B. Schiff1, Kristin M. Holland2, Deborah M. Stone2, J. Logan2,
Khiya J. Marshall2, Brandi Martell2, and Brad Bartholow2
1Department of Hematology, University of Washington, Seattle, WA, USA
2Centers for Disease Control and Prevention, National Center for Injury Prevention and Control,
Division of Violence Prevention, Atlanta, GA, USA
Abstract. Background: Suicides among men aged 35–64 years increased by 27% between 1999 and 2013, yet little research exists to examine
the nature of the suicide risk within this population. Many men do not seek help if they have mental health problems and suicides may occur in re-
action to stressful circumstances. Aims: We examined the precipitating circumstances of 600 suicides without known mental health or substance
abuse (MH/SA) problems and with a recent crisis. Whether these suicides occurred within the context of an acute crisis only or in the context
of chronic circumstances was observed. Method: Using data from the National Violent Death Reporting System and employing mixed-methods
analysis, we examined the circumstances and context of a census of middle-aged male suicides (n = 600) in seven states between 2005 and 2010.
Results: Precipitating circumstances among this group involved intimate partner problems (IPP; 58.3%), criminal/legal problems (50.7%), job/
financial problems (22.5%), and health problems (13.5%). Men with IPP and criminal/legal issues were more likely than men with health and/
or job/financial issues to experience suicide in the context of an acute crisis only. Conclusion: Suicides occurring in reaction to an acute crisis
only or in the context of acute and chronic circumstances lend themselves to opportunities for intervention. Further implications are discussed.
Keywords: suicide, crisis, middle-aged, mixed methods, qualitative
Suicide prevention efforts typically focus on either
youths, for whom suicide was the second leading cause
of death in 2013 but for whom rates are relatively low
(10.9/100,000), or adults over age 65, for whom suicide
was the 17th leading cause of death and rates are relatively
high (16.2/100,000; Centers for Disease Control and Pre-
vention [CDC], 2013a) compared to the national average
(12.6/100,000). The population that has consistently re-
ceived the least amount of attention is individuals in the
“middle years” between the ages of 35 and 64 years (Maris,
1995). In 2013, suicide was ranked as the fifth leading
cause of death for men and women (17.8/100,000) within
this age range, and this group carried the largest burden of
suicide, comprising over half of all suicides (CDC, 2013a).
Moreover, suicides increased 28.4% among middle-aged
Americans from 1999 to 2010 (CDC, 2013b). While the
increase was observed for both females and males (31.5%
and 27.3%, respectively), men make up more than 75% of
middle-aged suicides (16,769 vs. 5,538; CDC, 2013b) and
are therefore the focus of the current study.
In 1995, suicidologist Ron Maris stated: “We have a
problem right away. No one really knows very much about
midlife suicides” (p. 171). Almost 20 years later, based on
rates of suicide and increases in the middle years (CDC,
2013a, 2013b), this observation still appears true. In
2012, the National Action Alliance for Suicide Prevention
(NAASP) set the auspicious goal of saving 20,000 lives in
5 years (NAASP, 2012). Meeting this goal necessitates a
better understanding of the circumstances preceding mid-
dle-aged male suicide so that effective prevention strate-
gies can be developed and implemented. The current ex-
ploratory mixed-methods study intended to do just that.
Psychological autopsy studies consistently document
the role of mental illness in suicides (Brent, 1995; Cava-
nagh, Carson, Sharpe, & Lawrie, 2003; Harris & Barra-
clough, 1997; Isometsa, 2001) with 90% commonly cited
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men2
© 2015 Hogrefe PublishingCrisis 2015
as the proportion of suicides involving a mental illness.
Recent research suggests that this percentage may actual-
ly be much lower given differences in the definition of a
diagnosable condition and the possible over-diagnosis of
depression among decedents (Braithwaite, 2012; Milner,
Sveticic, & De Leo, 2013). Regardless of the proportion,
we know that most people with a mental disorder do not
attempt (Chen & Dilsaver, 1996) or die by suicide (Druss,
Zhao, Von Esenwein, Morrato, & Marcus, 2011; Malzberg,
1932). We also know that the stigma of mental illness and
cultural ideals of individualism in the US (Codony et al.,
2009) may preclude treatment for many people with men-
tal illness, particularly males; therefore, suicide prevention
efforts must extend beyond the identification and treatment
of mental illness.
Contributors to suicide, independent of mental illness,
include life events, such as a conflict with a partner, close
friend, neighbor, or relative; illness; unemployment; job
problems; and financial trouble (Foster, Gillespie, Mc-
Clelland, & Patterson, 1999; Heikkinen, Aro, & Lonn-
qvist, 1994). To date, many psychological autopsy studies
have focused on youths (Brent, Baugher, Bridge, Chen,
& Chiappetta, 1999), older adults (Harwood, Hawton,
Hope, & Jacoby, 2006), or suicides across the life course,
either matching on, or controlling for, age (Almasi et al.,
2009). Only two psychological autopsy studies exist, to
our knowledge, that specifically focus on middle-aged
adults. The first study focused solely on personality traits,
finding that suicide decedents versus controls who died
suddenly by other causes scored higher on neuroticism
(Draper, Kolves, De Leo, & Snowdon, 2013). The second
study examined suicides among men aged 30–49 in Hong
Kong and found that having at least one diagnosis, being
indebted, being unemployed or underemployed, never
married, and living alone were independent risk factors
for suicide compared with matched controls (Wong et
al., 2008). While these studies provide useful insight into
psychological characteristics and circumstances of suicide
decedents, they often include relatively small samples
thereby limiting their generalizability. The current study
sought to explore this gap by examining circumstances
of suicide among men in the middle years in a census of
male suicides in seven states. We focused particularly on
men without a known history of mental health or substance
abuse (MH/SA) problems and with stressful circumstances
in order to identify the most common or additional risk
factors for intervention.
Several studies and theories exist that attempt to explain
the pathway to suicide in cases for which psychopatholo-
gy is neither a necessary nor sufficient cause of suicide
(Molnar, Berkman, & Buka, 2001; Pompili et al., 2011).
For example, Shneidman (1996) recognized psychache
(i.e., severe psychological pain) as the “basic ingredient”
(p. 7) of suicide. He postulated that the best way to un-
derstand suicide is not through the study of mental illness
but rather through focusing on human emotions. Schotte
and Clum examined cognitive deficits in problem solving
and the relationship to hopelessness and suicidal behavior
(1982). A stress model of suicidal behavior suggests that
stressful life events may trigger suicidal behavior, even in
the absence of psychopathology (Paykel, Prusoff, & My-
ers, 1975). More recently, the stress–diathesis model and
the study of epigenetics considers proximal and distal risk
factors and their interaction (Turecki, 2014) as a suggest-
ed mechanism by which adversity impacts behavior. The
stress–diathesis model suggests, for example, that negative
antecedent life events such as early child abuse may serve
as a diathesis or constitutional vulnerability (van Heerin-
gen, 2012), which when paired with another stressor, such
as intimate partner problems or financial problems, may
increase the risk for suicide. Suicidal behavior may occur
early on in the life course or may set off what Maris dubs
the “suicidal career” (1981) with long-standing ideation
and/or attempts, or may accumulate to produce a “last
straw” effect (Pompili et al., 2011). Clinically, this may
manifest with some individuals being more vulnerable to
the effects of acute triggers (e.g., rejection), while others
endure chronic risk accumulation alone (described by Post
as kindling [1992]), and still others endure chronic risk
accumulation and then attempt suicide after a final acute,
triggering event (van Heeringen, 2012). It is on this chron-
ic accumulation of risk and acute (triggering) event rela-
tionship that we focus.
The objective of the current study is to first explore
contributing circumstances of middle-aged male suicides
where a crisis was noted and then to characterize whether
the suicide appeared as a reaction to an acute triggering
event or whether the suicide was the result of a chain of
accumulated or chronic stress.
To better understand the processes and circumstances pre-
cipitating middle-aged male suicide, the current study uti-
lizes an exploratory mixed-methods approach, stemming
from qualitative theory. Qualitative approaches provide
researchers with the tools to operationalize and establish
frameworks through inductive, open-ended, exploratory
examination of qualitative data (Creswell, 2007; Sofaer,
2002). To examine the available qualitative data of mid-
dle-aged suicides presented in this study, grounded theory
methodological techniques were used. Grounded theory
encompasses a process of inductive data collection and
analysis by examining themes and relationships present in
the data with the idea that theories and hypotheses emerge
throughout the data-driven analysis process (Creswell,
2007; Strauss & Corbin, 1994). In addition to utilizing this
qualitative approach to identify the various precipitators of
and circumstances surrounding these suicides, we further
quantified the precipitating circumstances that emerged
and analyzed the results using quantitative methods to bet-
ter isolate the most common themes present in the data
and, particularly, those precipitators that were common
among different groups of men.
This study is exploratory in nature and the first in a
series of studies our team designed to characterize suicide
among middle-aged adults. In addition to our primary
study objective to identify and characterize the circum-
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men 3
© 2015 Hogrefe Publishing Crisis 2015
stances in which suicide among middle-aged men occurs,
we had two methodological objectives of this initial work:
to develop a qualitative coding schema by which to iden-
tify and classify circumstances and themes present in the
death scene narratives (described later) and then to devel-
op and hone a mixed-methods analysis plan. Subsequent
work will use this structure from which to build upon and
examine other populations (e.g., middle-aged women) and
Data Source
The National Violent Death Reporting System (NVDRS)
is a large-scale surveillance system that captures details
on a variety of violent deaths including suicides. Specif-
ically, it collects information on decedent characteristics,
the means involved, and the precipitating circumstances
of death. Data sources for the NVDRS include law en-
forcement and coroner/medical examiner (CME) reports,
toxicology reports, and death certificates. All sources are
linked by incident. States manage data collection through
state health departments or subcontracted entities, such as
medical examiner offices. The process of investigating and
identifying precipitators of death used by these investiga-
tors typically consists of open-ended (i.e., qualitative) in-
terviews with next of kin about what were believed to be
the circumstances that contributed to death. The investiga-
tors document the circumstances that informants believed
resulted in, or contributed to, suicide. The data from law
enforcement officials and CMEs are gathered and coded
by trained NVDRS abstractors. The NVDRS has been de-
scribed in detail elsewhere (Paulozzi, Mercy, Frazier, Jr.,
Annest, & CDC, 2004).
Sample Selection
Our sample was selected from a census of suicides in sev-
en geographically dispersed NVDRS states (n = 11,859)
from the west, south, southeast, mid-Atlantic, and north-
eastern United States (Colorado, New Mexico, Kentucky,
Georgia, Maryland, New Jersey, and Massachusetts). Cas-
es were excluded if they had an NVDRS-defined mental
health, alcohol, or other substance problem (n = 7,335,
61.9%; CDC, 2010) and/or if no known circumstances
about the suicide existed (n = 1,820, 15.3%). Additionally,
given our focus on individuals without MH/SA problems
and given that research indicates that individuals who at-
tempt suicide multiple times are more likely than single
attempters to have a mental health disorder (Forman, Berk,
Henriques, Brown, & Beck, 2004), we excluded decedents
with a history of suicide attempts who were not already
excluded (n = 183, 1.5%). Finally, in order to elucidate
the context in which the crisis occurred, we excluded indi-
viduals who had not experienced a recent crisis as defined
by NVDRS (n = 1,896, 16%). Upon qualitative review, 25
(0.2%) cases were determined to be miscoded (i.e., they
had not experienced a recent crisis or they appeared to
have an MH/SA problem) leaving a total analytic sample
of 600 cases (5% of all cases and 23.8% of all cases with-
out MH/SA problems). Given the richness and depth of
the narrative data, the sample size was deemed sufficient
for identifying the major circumstances that contributed to
these suicides (Kendall et al., 2009; Owens et al., 2011). In
fact, upon review of an initial 60 cases, we reached satura-
tion (i.e., the point at which no new information added to
the development and understanding of the categories and
themes we had identified for coding purposes).
As stated, cases were selected into the study if decedents
were male, between the ages of 35 and 64, did not have
a known mental health or substance abuse problem, and
had experienced a recent crisis. NVDRS abstractors coded
relevant circumstances as recent crises per the established
NVDRS coding guidelines stating that the “victim experi-
enced a crisis within two weeks of the incident, or a crisis
was imminent within two weeks of the incident” (CDC,
2010, p. 119). If a circumstance was described as occurring
Figure 1. Classification of
the context of circumstances
precipitating suicide.
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men4
© 2015 Hogrefe PublishingCrisis 2015
“recently” by law enforcement, CMEs, or data abstractors,
we also defined and coded it as a recent crisis. We defined
all precipitating circumstances as acute, chronic, or acute-
on-chronic (Figure 1). The term acute is used to charac-
terize any recent crisis (i.e., a precipitator or circumstance
categorized by NVDRS data abstractors as “recent crisis”
or otherwise described in narrative data as having occurred
“recently”). Chronic circumstances included any circum-
stance that occurred over an extended period or outside the
2-week window characterizing acute circumstances (e.g.,
unemployment lasting 2 years). Acute-on-chronic circum-
stances involved a chronic situation as stated previously,
punctuated or exacerbated by an acute crisis; for example,
a decedent with a chronic health condition, such as cancer,
received a terminal prognosis the day prior to his suicide.
Because we selected cases based on crisis status, all of the
decedents included in this study experienced at least one
acute or acute-on-chronic circumstance.
Data Analysis
Data were analyzed in three phases. In Phase 1, study team
members developed a coding guide consistent with ground-
ed theory techniques (Glaser, 1998; Strauss & Corbin, 1998).
This involved a combination of narrative review, open cod-
ing (i.e., creating main categories of suicide circumstances),
axial coding (i.e., identifying patterns of underlying caus-
es, contexts, and consequences under each category), and
memo creation (i.e., notes outlining evolving theories and
hypotheses that emerge from the data). This process led to
a coding guide that included descriptive information about
decedents, 11 categories of contributing circumstances
(nonclinical mood issues [e.g., angry], adverse childhood
experiences, family history of mental health problems/
suicide, other problems of/with family members, intimate
partner problems [IPP], other relationship problems, phys-
ical health problems, criminal/legal problems, job/financial
problems, suicidal ideation, and recreational drug use);
evidence of premeditation (yes/no), and use of suicide pre-
vention/intervention strategies and opportunities (yes/no).
During development of the coding guide, a set of narratives
were coded until saturation was achieved to ensure that our
coding structure would fully capture the circumstances con-
tributing to suicides in our sample (Conrad, 1978; Corbin &
Strauss, 1990; Strauss & Corbin, 1990, 1994; Vaismoradi,
Turunen, & Bondas, 2013).
The current study focused specifically on elucidating
and detailing the descriptive information and circumstanc-
es that contributed to suicide cases among middle-aged
men in an effort to characterize those who die by suicide
and the types of crises that trigger suicide. We further di-
vided contributing circumstance categories into 60 sub-
categories (e.g., cancer, arguments with partner, pending
arrest) to detail the various types of problem experienced.
Finally, we coded the circumstance context (i.e., acute,
chronic, acute-on-chronic) for applicable subcategories
(e.g., recent cancer diagnosis was coded as an acute cir-
cumstance; ongoing arguments were coded as chronic; see
example, Table 1). Upon finalizing the coding guide, we
assessed intercoder agreement. Each study team member
coded 30 cases. Discrepancies were discussed and settled
in a roundtable setting. We reached an intercoder agree-
ment of 80%.
In Phase 2, we quantified the frequencies of each cat-
egory, subcategory, and context code. We then conducted
thorough thematic analyses of the categories and subcat-
egories with the highest frequencies to identify common
patterns (see example, Table 2). In Phase 3, we conducted
quantitative analyses. This included analyzing descriptive
statistics for the entire sample (Table 3) and for each of
the main categories identified (Table 4). We conducted chi-
square and t tests to examine differences between groups.
We used SAS (version 9.3) for all quantitative analyses.
Significance levels were set at p .05 for all tests.
Of the 600 men between the ages of 35 and 64 included
in the sample, 414 (69%) were non-Hispanic White, 100
(16.7%) were non-Hispanic Black, 49 (8.2%) were His-
panic, 14 (2.3%) were non-Hispanic Asian, four (0.7%)
were American Indian/Alaska Native, and 19 (3.2%) had
unknown/other racial/ethnic identities (see Table 3). The
Table 1. Sample narratives and codes applied
Narrative Codes applied
“42 [year old black male] died of self-inflicted [gunshot wound] to the head with a
12-gauge shotgun in a vehicle at a junkyard near residence. [Victim] had physical alter-
cation with wife1 and wife called authorities. [Victim] was on probation2 and feared he
would go immediately to jail3, so shot self in head. [Victim] disclosed intent4.”
1Intimate partner violence perpetration – acute
2Arrest/pending arrest/avoidance of jail or prison – chronic
3Unspecified legal/criminal problems – acute
4Disclosed suicidal intent to another person
“[Victim 1] (59, Hispanic, female) was found unresponsive at her residence with [Sus-
pect/Victim 2]1 (Male), [Victim 1]’s husband2, by their son when he could not get in
touch with them over the telephone. [Victim 1] was shot twice in the head by [Suspect/
Victim 2] while she was sleeping. [Victim 1] had been severely upset and depressed
over the recent death of son3. After killing [Victim 1], [Suspect/Victim 2] then shot
himself, he left a note4 at the scene and apparently had killed [Victim 1] because he
could not deal with her continuous crying and depression5. Currently no other informa-
tion is available.
2Homicide victim is suicide decedent’s spouse/partner
3Death of family member or friend – acute
4Left a note
5Other intimate partner problem – chronic
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men 5
© 2015 Hogrefe Publishing Crisis 2015
Intimate Partner Problems
Almost 60% of cases included IPP (n = 350), making them
the most frequent type of precipitating circumstance ex-
perienced (see Table 4, column A). Of this group, almost
two thirds of decedents were non-Hispanic White. Men
with IPP differed marginally in terms of race/ethnicity
from those without IPP (p < .10). The average age of dece-
dents in this category was 45.7 years; younger than those
who did not experience IPP (average age = 49.3 years;
p < .001). Men with IPP experienced between one and
eight of the 11 categories of circumstances, with an av-
erage of 2.5 categories noted per person. The number of
total circumstances noted among men with IPP was 940,
including 625 acute circumstances (average = 1.8/person),
224 chronic circumstances (average = <1/person), and 91
acute-on-chronic circumstances (average = <1/person). In
all, 51% of narratives with IPP occurred within the context
of an acute circumstance only, similar to those without IPP
(p > .05).
Qualitatively, of the 350 cases involving IPP, 147
(42%) narratives noted arguing between intimate part-
Table 2. Main categories of contributing circumstances among 600 male suicides with sample codes/subcodes and risk
periods noted
Main contributing circumstances
Specific types of circumstances
Quote examples
(including risk period/context)
Intimate partner problems (IPP)
n = 350 (58.3%)
Argument/fighting (verbal arguing only)
Abandonment or separation
Divorce or break-up
Intimate partner violence victimization
Intimate partner violence perpetration
Other intimate partner problems
“Three days ago [acute] the victim went to
the town where she worked; they saw each
other but the ex-girlfriend would not talk to the
victim because their supervisors had told them
to stay away from each other. The victim had
been working as a mechanic in this town but he
was recently transferred to a different location
because of the problems that the couple was
having [acute-on-chronic]. When the victim
was leaving the town where the ex-girlfriend
worked, he was stopped for speeding by a
different officer and received a ticket [acute].
Criminal/legal issues
n = 304 (50.7%)
Sexual misconduct or allegations of sexual
Drug/alcohol-related offense
Arrest or pending arrest or avoidance of jail/
Incarceration (or release from incarceration)
Other unspecified legal or criminal problems
or accusations
“The victim had been arrested on felony drug
charges and was facing 16 years of prison
time. He had failed to appear for the last court
hearing and there was a warrant out for his
arrest [acute].”
Physical health issues
n = 81 (13.5%)
Chronic disease
Physical pain
Other physical issues
“[The] victim was fired from job approximately
two weeks prior to the incident [acute] and was
stressed out about money and wondering how
V was going to take care of family. Victim was
also having stomach problems and was sched-
uled to see an oncologist and is the reason for
victim losing job [acute-on-chronic].”
Job/financial problems
n = 135 (22.5%)
Problems with coworkers
Unemployment problems
Other job-related difficulties
Home foreclosure/lost home
Debt problems
Insurance/disability/benefits problem
Other financial problems not otherwise
“Notes present citing homelessness, jobless-
ness [chronic], argument with father [acute],
and previous jail time [chronic].
“Victim was being served notice of foreclosure
and eviction [acute]. Victim complained of be-
ing nervous and suffering from anxiety attack.
Within the past year, victim’s wife had left him
and had lost his job [chronic].”
average age at death was 47.2 years. Nearly two thirds of
all suicides occurred via firearm, 20% from hanging/stran-
gulation, and roughly 7% each from poisoning and other
Overall, 1,453 known precipitating circumstances, in-
cluding 966 acute, 331chronic, and 156 acute-on-chronic
circumstances, were identified as problems that contribut-
ed to suicide among the 600 cases. More than 50% of cases
involved acute conditions only (n = 307). The remaining
cases involved the presence of other circumstances that
were coded as chronic or acute-on-chronic. On average,
narratives noted that decedents experienced 2.2 of the 11
categories identified as contributing circumstances in the
coding guide. Four categories commonly noted included
IPP, criminal/legal problems, physical health problems,
and job/financial problems. Finally, our qualitative analy-
sis uncovered clear themes regarding disclosure of suicid-
al intent or ideation (i.e., evidence of premeditation), with
individuals who experienced IPP, criminal/legal problems,
physical health problems, and job/financial problems pre-
meditating about suicide at different rates. These results
are described in detail here.
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men6
© 2015 Hogrefe PublishingCrisis 2015
ners. The majority of these arguments (n = 131; 89%)
occurred immediately prior to the suicide and were cod-
ed as acute. Divorce and break-ups were noted in 117
(33.4%) of the 350 IPP cases, again with many cited as
having occurred recently, and therefore noted as acute.
Seventy-two (20.6%) IPP cases involved intimate part-
ner violence (IPV) perpetration, with more than half of
these (n = 37) identified as having occurred recently, and
therefore categorized as acute. Fifty-two (14.9%) cases
involved separation (i.e., the partner leaves the household
or otherwise physically separates from the victim). Most
of these cases (n = 37; 71.2%) occurred proximal to sui-
cide and were therefore coded as acute. For example, the
partner “left” or had “moved… 2 weeks… [prior] to get
away from” decedent. Thirty-seven (10.6%) narratives
noted infidelity or accusations of infidelity. Other IPP, not
identified above, occurred in 51 (14.6%) cases and were
primarily chronic in nature. Many narratives indicated
that more than one IPP occurred simultaneously; for ex-
ample, the decedent “and his wife were going through a
divorce… [and] authorities had been dispatched to the
location prior on domestic violence calls.” Additionally,
many cases involved continual problems within the inti-
mate partner relationship (e.g., the suicide victim “and
his wife [were] going through the process of a divorce,
but [had] not formally filed the paperwork. They were
fighting because she would not have sex with him”). This
narrative demonstrates the co-occurring nature of differ-
ent forms of IPP and the context of these subcategories
(i.e., acute, chronic, or acute-on-chronic risk).
Finally, 28.6% of men who experienced IPP premed-
itated suicide, either expressing suicidal ideation prior to
death, making a disclosure to a family member, friend, or
other person, or writing about their suicidal intent before
death. A common theme that emerged regarding disclosure
among this group was that men disclosed intent immedi-
ately prior to the suicide (e.g., “The couple argued, and
the victim made several suicidal comments about hanging
himself in the garage”).
Criminal/Legal Issues
Criminal and/or legal issues preceded half of all suicides
examined in this analysis, 304 (50.7%; see Table 4, col-
umn B). People experiencing criminal/legal issues were
more often non-White compared with people without
criminal/legal issues (p < .001). They also tended to be
younger (average = 46.3 years) than people without crim-
inal legal issues (average = 48.1 years; p < .001). People
in this group experienced between one and nine categories
of circumstances (average = 2.3/person). Narratives in this
group noted 781 circumstances: 563 acute circumstances
(average = 1.9/person), 145 chronic circumstances (aver-
age = <1/person), and 73 acute-on-chronic circumstances
(average = <1/person). Fifty-four percent (n = 165) of nar-
ratives with criminal/legal problems occurred within the
context of an acute issue only. This finding was similar to
the distribution among those without a criminal/legal issue
(p > .05).
Of the 304 decedents categorized as experiencing
criminal and/or legal issues, 40.8% committed 139 acts
of homicide and 37 acts of attempted homicide prior to
suicide. Intimate partners or former intimate partners
(n = 99) were targeted in 71.2% of homicides and in 48.6%
of attempted homicides (n = 18). Other family members
were targeted in 25 (18%) homicides and five (13.5%) at-
tempted homicides. Seventy-percent of intimate partner
homicides also involved another IPP. For example, 25.3%
(n = 25) occurred within the context of a recent (acute)
argument: “Victim and [wife] had been having marital
problems and were arguing the day of the incident. They
decided to separate. Victim left and then came back and
shot [wife], then shot himself in the chest.” Ten percent of
intimate partner homicides occurred within the context of
a recent (acute) divorce or break-up. For example: “The
couple[s] were separated and in the process of divorcing…
The couple had no attorneys and was trying to resolve the
property settlement on their own; they were having diffi-
culties.” A further 14.1% occurred in the context of chron-
ic issues associated with divorce.
Table 3. Sample descriptive information (n = 600)
Non-Hispanic White 414 69.0
Non-Hispanic Black 100 16.7
Hispanic 48 8.0
Non-Hispanic Asian 15 2.5
Non-Hispanic AI/AN 4 0.7
Unknown/other 19 3.2
Average age 47.2 years
Firearms 391 65.0
Hanging 129 21.5
Poisoning 39 6.5
Other 41 6.8
Acute 966 66.5
Chronic 331 22.8
Acute-on-chronic 156 10.7
Total 1,453 100.0
Acute only 307 51.2
Acute-on-chronica 293 48.8
Total 600 100.0
Note. AI/AN = American Indian/Alaska Native.
aIncludes acute plus chronic, chronic and acute-on-chronic, or
acute-on-chronic only problems.
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men 7
© 2015 Hogrefe Publishing Crisis 2015
Among all criminal-legal cases, 88 (28.9%) occurred
in the context of a recent (acute) arrest or warrant for ar-
rest; for example, the decedent “was facing jail time for a
domestic violence charge that his son had testified against
him.” Of these cases, 37 (42%) victims died within mo-
ments of contact with law enforcement (e.g., upon routine
traffic stops or upon being served a warrant). Fifty-eight
cases (19.1%) occurred in the context of an acute or acute-
on-chronic incident involving a restraining order being
served or violated; for example: “The victims was de-
scribed as being very dominating and abusive toward the
[wife]. [She] was in the process of obtaining a restraining
order against the victim and had moved to a different town
2 weeks ago to get away from the victim.
Twenty men (6.6% of subjects with criminal/legal
problems) died while in custody, with most of these cas-
es occurring via hanging/strangulation in their jail cell or
holding area. Another nine men had just been released
from jail/prison, five had a history of incarceration, and
12 were either going to jail or fearful of pending incarcer-
ation. Crimes that preceded suicide involved recently dis-
covered sexual misconduct (n = 41), including child sex-
ual molestation (n = 27), possession of child pornography
(n = 8), and rape (n = 6); alcohol (driving under the influ-
ence) or drug possession or trafficking (n = 22; 18 acute);
and other felonies such as fraud, robbery, kidnapping, hit
and run, and burglary.
About 20% of men who experienced criminal/legal
problems exhibited apparent signs of premeditation. Men
in this category often indicated suicidal intent or ideation
through disclosures made immediately before their death
and often as a result of the decedent learning of criminal or
legal allegations against him. For example, “An emergency
call was placed from victim’s daughter reporting that she
was on the phone with victim and that he stated that he was
going to commit suicide. Domestic violence papers were
found at the residence inside a truck that was owned by vic-
tim and had a severance date of the day prior to this event.”
Table 4. Suicides among people with intimate partner problems, criminal legal issues, physical health issues, and/or job/
financial issues by race/ethnicity, age, and context (n = 600)a
A. Intimate partner
problems (IPP)
B. Criminal/
legal issues
C. Physical health
D. Job/
financial problems
Yes, n = 350 Yes, n = 304 Yes, n = 81 Yes, n = 135
White (%) 65.1 60.9 75.3 77.0
Black 20.3 23.0 7.4 6.7
Hispanic 8.0 10.2 9.9 6.7
Asian 2.9 3.0 2.5 3.7
AI/AN 0.6 1.0 0 0
Unknown/other 2.6 2.0 4.9 5.9
Total % 100 100 100 100
χ2(df)b9.4(5)~ 28.8(5)*** 7.3(5) 18.8(5)**
Average age (years) 45.7 46.3 52.7 48.6
t(df)b5.6(598)*** 2.8(598)** −6.9(598)*** −2.4(598)*
Average no. of problem
categories experiencedc 2.5 2.3 2.7 2.8
Acute issues only 51.1% 54.3 25.9 40.7
Acute and chronic
issuesd48.9% 45.7 74.1 59.3
χ2(df) .0002(1)b2.4(1)b23.9(1)***b7.6(1)**b
Premeditation 28.6% 19.4 23.5 22.2
χ2(df)b11.2(1)*** 19.4(1)* 23.5 22.2
Note. AI/AN = American Indian/Alaska Native.
aCategories are not mutually exclusive making column totals add to more than 600. bComparison made between those with problem indicated and those without.
cEleven problem categories possible: mood problems (not clinical), adverse childhood experiences, family history of mental health problems/suicide, other
problems of/with family members, intimate partner problems (IPP), other relationship problems, physical health problems, criminal/legal problems, job/fi-
nancial problems, suicidal ideation, and recreational drug use. dIncludes acute plus chronic, chronic and acute-on-chronic, or acute-on-chronic only problems.
~ p <. 10. * p < .05. ** p < .01. *** p < .001.
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men8
© 2015 Hogrefe PublishingCrisis 2015
Physical Health Issues
Eighty-one narratives (13.5%) included reference to phys-
ical health problems (see Table 4, column C). Suicides
among people with health issues did not differ in race/
ethnicity from suicides without health issues; however,
they tended to be older (average = 52.7 years) than their
counterparts without health issues (average = 46.3 years).
Cases with health conditions noted between one and eight
categories of circumstances present, with an average of
2.7 per person. Narratives noted 228 circumstances and
included 104 acute circumstances (average = 1.3/person),
85 chronic issues (average = 1/person) and 39 acute-on-
chronic problems (average = <1/person). A little more than
a quarter of these problems occurred within the context of
an acute issue only. People with health issues were more
likely to have acute and chronic issues (p < .001).
Among people with health issues noted, 27 (33.3%)
experienced multiple health problems. For example, one
case involved a man who had “severe health problems and
was told that he only had six months to live due to prob-
lems with his heart, liver and kidneys.” Health problems
included four categories, primarily: cancer, chronic dis-
ease, physical pain, and “other” physical issues. Cancer
was present in 20 (24.7%) of the 81 physical health-related
cases; 12 narratives described acute, three described chron-
ic, and five described acute-on-chronic cancer-related
complications or diagnoses. Thirty-two of 81 men (39.5%)
experienced chronic disease (e.g., heart disease). Of these,
27 had chronic issues associated with their disease, and
five experienced acute or acute-on-chronic events relat-
ed to their disease(s). For example, one victim had been
“diagnosed with bone cancer at the start of the year…
[He] had just had a doctor’s appointment where he found
out that the cancer had come back.” In addition, physical
pain was indicated as a precipitating circumstance for 22
(27.2%) men, with nine of these men (45.0%) experienc-
ing acute-on-chronic pain (e.g., pain over a long period,
punctuated by an acute episode of pain that served as a
recent crisis, or possible trigger for suicide). Finally, 42
men experienced other physical health circumstances,
such as surgeries, asthma, stomach ailments, hepatitis C,
among others, in varying contexts. For instance, “Victim
was diagnosed with cancer and hepatitis C [chronic] and
was recently given by doctors six months to live [acute-
on-chronic]… Recently, the victim had coughed so hard
that he broke a few ribs [acute]… The victim did not have
health insurance [chronic] and often drank alcohol to ease
his pain [chronic].”
Nearly one quarter (23.5%) of men whose suicides
were precipitated by physical health problems had previ-
ously disclosed suicide intent or experienced suicidal ide-
ation. These men often had ongoing health problems, and
often indicated suicidal intent in relation to their failing
health: “Victim left a suicide note in the vehicle; it said that
the victim did not want to live with the pain anymore, and
he had taken his own life.
Job/Financial Problems
Job/financial problems occurred in 135 (22.5%) cases
(see Table 4, column D). Non-Hispanic Whites comprised
more than three quarters of this group. This was similar to
the percentage without job/financial issues (p > .05); how-
ever, this group tended to be older (average = 48.6 years)
than the group of suicides without job/financial problems
(average = 46.8 years). Men with job/financial problems
experienced between one and eight of the 11 precipitating
circumstance categories, with an average of 2.8 per person.
Overall, this group experienced 421 preceding circum-
stances as noted in the narratives. This included 233 acute
circumstances (average = 1.7/person), 134 chronic circum-
stances (average = 1/person) and 54 acute-on-chronic cir-
cumstances (average < 1/person). About 41% of narratives
with job/financial problems occurred within the context
of an acute circumstance only. This proportion was sig-
nificantly less than the proportion of people without job/
financial problems, p < .01.
Seventy-seven men (57%) experienced job-related
problems specifically. Among them, a majority (n = 46;
59.7%) noted unemployment issues, for example, one
decedent “had been unemployed for quite some time…
[and] had been unsuccessful in repeated attempts to get
work.” In addition, decedents also experienced “other”
job-related issues (n = 26; 33.8%), such as job termi-
nation, uncertainty of future job status, and demotion.
Among cases indicating financial concerns specifically
(n = 92; 68.1%), incidents included home foreclosure
or loss of one’s home (n = 34; 37.0%), debt issues (n
= 8; 8.7%), and unspecified financial problems (n = 54;
58.7%). Thirty-four (25.2%) of job/financial concerns in-
cluded both job and financial problems. For example, one
decedent wrote in a suicide note, which was paraphrased
by the death scene investigator, that he was “struggling
in his business and [had undescribed] problems with
his business partner… [and] financial problems due to
situation with [his] business.” Over one fifth (22.2%)
of individuals in the job/financial problem category ex-
pressed premeditation with suicide notes often referenc-
ing mounting debt.
After examining these results, we conducted a post hoc
hypothesis test to determine whether decedents with IPP
or criminal/legal issues (n = 370) would be more likely
than those with health or job/financial problems (n = 198)
to experience acute circumstances only. We found that
56% of the former group experienced acute circumstanc-
es only compared with 36.4% of the latter group, thereby
supporting our hypothesis, χ2 = 19.8(1), p < .001. Finally,
as noted in Table 4, we found that men who had experi-
enced IPP were more likely to have premeditated about
their suicide (i.e., had suicidal ideation, disclosed verbal-
ly or in writing) than those without IPP problems, while
those who experienced criminal/legal problems were less
likely to premeditate compared with their counterparts
without criminal/legal problems. There were no significant
differences in premeditation between men with and with-
out health or job/financial problems.
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men 9
© 2015 Hogrefe Publishing Crisis 2015
This study sought to examine the nature and context of the
crises and other circumstances preceding suicide among
a group of middle-aged men without MH/SA problems
and with recent crises. As a result of this exploratory
mixed-methods analysis, four primary categories of su-
icide precipitators emerged: IPP (58.3%), criminal/legal
issues (50.7%), physical health issues (13.5%), and job/
financial problems (22.5%). Our analysis revealed that
IPP and criminal/legal issues occurred about equally in
the context of acute and acute-on-chronic risk, while
health stressors and job/financial problems occurred more
frequently in the context of acute-on-chronic risk. When
we compared the former two groups with the latter two
groups, we found that crises among men with IPP and
criminal/legal issues more frequently occurred in the con-
text of acute risk only.
Our study both concurs and diverges from psycho-
logical autopsy findings. For instance, a Finnish study by
Heikkinen, Isometsa, Aro, Sarna, and Lonnqvist (1995)
examined life events in the 3 months prior to suicide (n =
1,022) and found that separation was the most prevalent
circumstance among the 40–49-year-old age group, occur-
ring in 21.8% of cases. IPP occurred much more frequent-
ly in our sample of men, 58.3%. This likely resulted from
our extensive definition of IPP, which ranged from argu-
ments and divorce/break-ups to IPV perpetration.
Heikkinen and colleagues (1995) further noted that
physical health issues contributed to a range of deaths –
from 11% in the 40–49-year-old group to 48.1% in the
60–69-year-old group. This finding aligns with our re-
sults and indicates that older versus younger individuals
are more likely to suffer a physical health problem. With
respect to preceding job/financial and criminal/legal prob-
lems, our study found similar rates to those reported by
Heikkinen et al. in two separate studies (Heikkinen et al.,
1994; Heikkinen et al., 1995).
Interestingly, a study of adolescent suicides indicated
that 25% of cases without psychiatric problems, compared
with 4% with such problems, had been involved with the
legal system prior to suicide (Marttunen et al., 1998).
This suggests that criminal/legal problems may be more
prevalent among suicide decedents without known mental
health disorders. This aligns with our sample that included
a large percentage of criminal/legal issues; however, in an
effort to further elucidate the antecedents of suicide among
middle-aged Americans, our future research will focus on
examining whether middle-aged men with mental health,
substance abuse problems, and a history of suicide at-
tempts experience similar crises and circumstances within
the same context as men without such problems.
The current work has several notable strengths. Unlike
psychological autopsy studies that primarily focus in depth
on examining the presence or absence of psychiatric disor-
ders (Barraclough, Bunch, Nelson, & Sainsbury, 1974; Ca-
vanagh et al., 2003; Conwell et al., 1996; Isometsa, 2001),
the current study examined suicides among individuals
without an identified mental health disorder. Additionally,
most psychological autopsy studies examine older adults
or youth (Dervic, Brent, & Oquendo, 2008; Duberstein,
Conwell, Conner, Eberly, & Caine, 2004; Pompili et al.,
2008); few have studied middle-aged adults – a growing
segment of the suicide population – either exclusively or in
an in-depth qualitative fashion. In addition, NVDRS pro-
vided the opportunity to carry out a mixed-methods anal-
ysis and to do so using a large sample consisting of an en-
tire eligible census of suicides in multiple states. The large
number of cases and the method by which the data were
coded and analyzed in this study are virtually unmatched
and will undoubtedly be considered a major contribution
to the field of qualitative research and suicide prevention.
This large sample enabled us to uncover a breadth of cat-
egories and themes all in a lower-cost and more efficient
manner compared with traditional psychological autop-
sy studies (Isometsa, 2001). From this process we began
to identify areas of potential intervention and prevention
grounded in the data (i.e., narratives). For future analyses,
we plan to address the broader generalizability of our find-
ings by examining more states implementing NVDRS.
The study results should be considered in light of sever-
al limitations. First, the quality of NVDRS data varies by
state, with some narratives containing relatively extensive
detail and others containing notably less information.
Second, NVRDS narratives consist of details from key
informants who may be unaware of all important contrib-
uting circumstances. For example, key informants may
be unaware of prior suicide attempts or decedent mental
health disorders, two of our primary exclusion criteria.
Additionally, information provided may be biased given
the often emotional context of the suicide and its investi-
gation. However, these limitations are a general limitation
of the postmortem interview methodology (Cavanagh et
al., 2003) and not specific to this study alone. Third, our
results are not generalizable to the population of all mid-
dle-aged male suicides without known MH/SA problems
and with a recent crisis, as we examined cases from seven
states only. However, NVDRS (at the time of this anal-
ysis) included only 15 states so this would have been a
limitation even had we included all states. While we in-
cluded cases from most regions of the US, the northwest
and southwest regions were not included, which may have
resulted in identification of different circumstances relat-
ed to suicides. Fourth, while we selected cases based on
no indication of an NVDRS-defined MH/SA problem, we
cannot be certain that the decedents did not in fact have a
disorder such as a personality disorder, more likely to get
overlooked. We do know, however, that an undiagnosed,
untreated, or otherwise hidden diagnosis may be com-
mon among males (Codony et al., 2009). Finally, while
L. B. Schiff et al.: Risk Preceding Suicidal Crises Among Middle-Aged Men10
© 2015 Hogrefe PublishingCrisis 2015
some may consider our sample size small, these 600 cases
(n = 600/2,521) represent nearly one quarter (23.8%) of all
non-MH/ SA-related cases among males in the age group
in the seven states.
Implications and Future Research
The results of this study have implications for research,
practice, and policy. From our analysis, it appears that
IPP, criminal/legal issues, health, and job/financial con-
cerns play an important role in suicide among men without
known MH/SA problems. Understanding the context of
these issues in men’s lives may be useful when develop-
ing suicide prevention programs or when assessing risk.
For example, identification of chronic risk factors, such as
ongoing health problems, in the context of acute or recent
financial issues, may alert professionals (e.g., legal, medi-
cal, work place) to better support individuals who may be
vulnerable to the effect of accumulating stress. Assessing
interpersonal conflicts, other difficulties at home or work,
social support, and coping strategies in such situations
may help identify at-risk men and facilitate referrals to ap-
propriate services.
Public health professionals, social service profession-
als, and researchers may benefit from considering not only
prevention for middle-aged men but from considering up-
stream prevention with boys and young men. For example,
implementation and evaluation over time of dating vio-
lence prevention curricula in middle and high schools and
greater emphasis on coping, problem solving, help seek-
ing, and connectedness to positive peers and trusted adults
early on may all work to stem later crises. Additionally,
researching the motivations, or lack thereof, for help seek-
ing at different ages, and developing and testing effective
interventions that increase help seeking, linkage to care,
and service utilization may help support males of all ages.
Implications also exist for the general public by way
of health literacy for suicide prevention, that is, knowing
the risk and warning signs for suicide and taking appropri-
ate action (Owens et al., 2011). For example, results indi-
cated that nearly one in five decedents exhibited apparent
premeditation regarding their suicide. In some cases, this
was done very directly, “Now I’m going to kill myself.”
In other cases it was more indirect, “Everybody would be
much better off if I weren’t around.” Strategies aimed at
increasing awareness about the seriousness of this kind
of disclosure and ways to connect at-risk individuals with
prevention resources may save lives. Similarly, promoting
norms that sanction suicide-laden terminology in every-
day vernacular, for example, “I am so frustrated, I could
shoot myself,” may prevent people from disregarding or
mistaking serious intention or cries for help. Additional-
ly, normalizing conversation related to emotions and en-
couraging openness with men and young boys about their
stressors may support connectedness and social norms
change, so that males of all ages feel more comfortable
receiving support and seeking help when needed. Finally,
results may inform postvention interventions and preven-
tion for survivors who may feel guilt or shame or who may
suffer in other ways not typically acknowledged (e.g., fi-
Our future research will seek to examine whether mid-
dle-aged men with MH/SA problems and/or history of sui-
cide attempts experience similar precipitators of suicide as
those described herein. We also plan to extend our coding
structure to examine antecedents of suicide among a sam-
ple of middle-aged women. To further strengthen our study
and to make our quantitative findings more generalizable,
we will include data from additional states/regions in the
NVRDS dataset.
In 2012, the NAASP stated an auspicious goal of saving
20,000 lives from suicide in the next 5 years (NAASP,
2012). Effective prevention strategies for middle-aged
men, who comprise the bulk of all suicides, would help
reach this goal. Through exploratory and mixed-method
approaches, a better understanding of the precipitating
circumstances and context of suicide among middle-aged
men can inform an effective response to prevent these un-
necessary deaths.
The findings and conclusions in this report are those of the
authors and do not necessarily represent the official po-
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Received July 31, 2014
Revision received February 16, 2015
Accepted February 23, 2015
Published online June 30, 2015
About the authors
Lara B. Schiff, MPH, is a research manager in the Department of
Hematology at the University of Washington, Seattle, WA, USA.
She leads a clinical research team and supports research program
planning and development. Lara’s research interests include
mixed-methods evaluation approaches to program development,
implementation, and assessment.
Kristin M. Holland, PhD, MPH, is a behavioral scientist in the
Centers for Disease Control and Prevention Division of Violence
Prevention, Atlanta, GA, USA. There, she leads the School-As-
sociated Violent Death Surveillance Study, which collects quali-
tative and quantitative data on all violent school-related fatalities
in the US. Kristin’s research interests include suicide and youth
violence etiology, surveillance, and prevention.
Deborah M. Stone, ScD, MSW, MPH, is a behavioral scientist
in the Centers for Disease Control and Prevention Division of
Violence Prevention, Atlanta, GA, USA. There she conducts in-
tramural research with a focus on both risk and protective factors
for suicide in high-risk groups and collaborates on effectiveness
studies evaluating what works in suicide prevention.
J. Logan, PhD, is a staff scientist at the Centers for Disease Con-
trol and Prevention, Atlanta, GA, USA. His research uses the
public health approach to improve understanding of the anteced-
ents of homicide, suicide, youth violence, prescription drug over-
dose, and homicide followed by suicide. He has also investigated
multiple epidemics of self-directed violence in the US.
Dr. Khiya J. Marshall, PH, is a behavioral scientist in the Centers
for Disease Control and Prevention Division of Violence Preven-
tion, Atlanta, GA, USA. There she conducts research focused on
the implementation and evaluation of evidence-based youth vi-
olence prevention programs. Khiya’s research interests include
youth violence, suicide prevention, and intimate partner violence.
Brandi N. Martell, MPH, is an ASPPH fellow in the Centers for
Disease Control and Prevention Division of Violence Prevention,
Atlanta, GA, USA. She evaluates the effectiveness of youth vi-
olence training and technical assistance provided to local health
departments. Brandi’s research interests include alcohol use as a
risk factor for youth violence perpetration, suicide, and health-
care use.
Brad Bartholow, PhD, is Team Lead for the Youth Violence, Su-
icide, and Elder Maltreatment Team in the Division of Violence
Prevention at the U.S. Centers for Disease Control and Preven-
tion, Atlanta, GA, USA.
Lara B. Schiff
2829 Franklin Avenue E. #N3
Seattle, WA 98102
Tel. +1 206 898-0819
... However, middle-aged men have been ignored in Chinese suicide research. The research in high-income countries, like the USA, suggested that suicides among this group have been increasing (Schiff et al., 2015). There are many factors contributing to suicide, including problems in marriage, finance, health, and interpersonal relationships (Schiff et al., 2015). ...
... The research in high-income countries, like the USA, suggested that suicides among this group have been increasing (Schiff et al., 2015). There are many factors contributing to suicide, including problems in marriage, finance, health, and interpersonal relationships (Schiff et al., 2015). Many rural males are reluctant to seek help if they have a mental illness. ...
Rationale: In China, a large number of men are being squeezed out of the marriage market due to a shortage of marriageable women. Previous research has largely discussed the consequences of gender imbalances and focused on the behavior of marriage-squeezed men that threatens public safety. No empirical studies explored the impact of the social environment on risky behaviors of marriage-squeezed men. Objective: The main objective of this paper is to examine whether social discrimination is associated with marriage-squeezed men's engagement in the behaviors that threaten their own wellbeing and community safety. Method: Using individual-level data collected in Chaohu City, Anhui, this study employed binary logistic regression and linear regression to examine the impacts of discrimination on alcohol use disorder and suicidal ideation, respectively. Ordinary least squares regression was performed to predict the effects of discrimination on gambling and verbal conflict based on village-level data collected in 380 villages across 18 provinces in China. Results: The results showed that self-reported discrimination was positively associated with incidence of alcohol use disorder and suicidal ideation among marriage-squeezed men; villagers' discrimination was also positively associated with the number of marriage-squeezed men in the village who often gambled or were in conflict with others. Conclusions: Evidence suggests that social discrimination is one important mechanism that triggers marriage-squeezed men to engage in risky behaviors that threaten self- and community safety. Commonly held stereotypes about rural bachelors is one of the reasons that causes marriage-squeezed men to pose a threat to public safety. It is necessary to develop and implement policies aimed at creating a friendly and tolerant social environment for marriage-squeezed men.
... Staff attrition adds to the relational losses and unpredictability of the children's lives and is therefore a direct risk factor for these vulnerable children. Further, it has been documented that care workers are likely to under-report traumatic stress, perhaps due to their expectations of the emotional tole of the work (Schiff et al., 2015). Traumatic stress specifically attributed to role-related stress may therefore go unreported across caring professions and thus under-supported, resulting in accelerated burnout and stress-related leave. ...
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Currently, 78,150 children are in care in England, with 11% of the most vulnerable living in 2,460 residential homes due to multitype traumas. These children require safe and secure trauma‐informed therapeutic care. However, the children's residential care workforce delivering this vital care is an unrepresented, under‐researched and largely unsupported professional group. The workforce undertakes physically and emotionally challenging work in difficult conditions, exacerbated by the COVID‐19 pandemic. Practitioner wellbeing is directly associated with outcomes for children. Therefore, we sought to understand how experiences within the workforce could improve overall working conditions, and thus outcomes for staff and children. Thirty participants took part in a survey, providing feedback on their experiences and the situations they faced during the English lockdown April‐June 2020. Two participants also opted to take part in a teleconference interview, rather than survey, although were asked the same questions. Data were analysed through thematic analysis. A stakeholder advisory board supported the project, including frontline staff, care leavers, service managers and policy researchers. The advisory board assisted in reflecting on the data from the survey and interviews to generate a complete analysis. Overall, staff require facilitated safe spaces for peer‐support, reflective and emotionally supportive supervision. An organisational awareness that staff wellbeing is intrinsically connected to the wellbeing and therapeutic outcomes of the children they care for is essential. Further, staff require a sense of belongingness to feel safe and competent in their role due to a lack of external recognition and professional representation or validation. Based on the findings of the study and an iterative process with the stakeholder advisory board, we created a Wellbeing Charter for adoption within organisations to promote and protect the wellbeing of this vital workforce. The COVID‐19 pandemic has exposed professional, financial and environmental inequalities that affect these frontline workers. Implementing organisational, statutory and policy‐driven initiatives to prioritise their wellbeing are essential for the vulnerable children they care for.
... To assess intercoder agreement, three coders independently reviewed and coded 10 identical cases each using a method previously documented in the literature (Schiff et al., 2015). The initial rate of intercoder agreement was 80%. ...
To gain a better understanding of military suicide, we examined suicide narratives for 135 Soldiers extracted from two large-scale surveillance systems: the Department of Defense Suicide Event Report (DoDSER) and the Centers for Disease Control and Prevention’s (CDC) National Violent Death Reporting System (NVDRS). Using coroner/medical examiner and law enforcement narratives captured in the NVDRS and mental health provider narrative data collected across multiple domains from the DoDSER, we examined circumstances surrounding military suicides using a qualitative content analysis approach. We identified five common proximal circumstances: (1) intimate partner relationship problems (63.0%); (2) mental health/substance abuse (51.9%); (3) military job-related (46.7%); (4) financial (17.8%); and (5) criminal/legal activity (16.3%). Evidence of premeditation was present in 37.0% of suicides. Decedents frequently struggled with multiple, high-stress problems and exhibited symptoms of coping and emotion regulation difficulties. Findings demonstrate potential points of intervention for suicide prevention strategies.
... Both types of suicide were triggered by underlying health problems and intimate partner conflicts, which was also observed in other literature on suicide. 29 However, as financial difficulty was found more frequently among males who committed suicide, 30 it is reasonable that it constitutes a bigger part of the triggers in suicide by paraquat, where the subjects were predominantly male. ...
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Objective Rodenticide as a means of suicide has been documented for centuries. However, this method is often discussed in conjunction with other pesticides. Thus, we aimed to focus on patients who committed suicide with rodenticide and compared them with those who used paraquat for suicide, another frequently used yet lethal method, to highlight the different psychopathology of patients who choose rodenticide as their means of suicide. Methods A 12-year retrospective chart review was conducted on the medical records of all patients admitted to Chang Gung Memorial Hospital due to attempted suicide by either rodenticide or paraquat. Psychiatric consultation sheets were collected to ascertain the psychiatric comorbidity and the major stressor for suicide, measured by the Social Readjustment Rating Scale. A χ² test and logistic regression were used for group comparisons. Results Seventeen rodenticide and 157 paraquat suicide attempts were identified. Compared with suicides by paraquat, suicides by rodenticide had a more even distribution in the gender ratio but a lower Social Readjustment Rating Scale score (p<0.001). Depressive disorder was the most common diagnosis in suicides by rodenticide and paraquat. However, schizophrenia and psychotic disorder (29.4%) was the second most common diagnosis and a significant predictor of suicide by rodenticide (odds ratio =9.21, 95% confidence interval =1.2–66.07, p=0.027). Conclusion High comorbidity of psychosis in suicide by rodenticide warrants disease-specific suicide prevention and additional large-scale research to confirm this association.
... Studies have not examined precipitating factors for or circumstances of suicide among decedents. Such data on factors that precipitate suicide [14][15][16][17] have guided targeted prevention efforts for groups such as middle-aged men and military and veteran populations. [18][19][20][21] Identifying factors that influence suicide risk among people with a history of cancer can identify opportunities for suicide prevention. ...
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Objective Cancer can trigger psychological distress, which may be associated with risk of suicide. We explored precipitating circumstances of suicides among decedents with and without a history of cancer. Methods Coroner or medical examiner and law enforcement narratives of adult suicides were coded from 17 participating states in CDC's National Violent Death Reporting System during 2004–2013. Bivariate and multivariate analyses examined associations between cancer history and factors that precipitated suicide. Results Of 90,581 suicides, 4,182 decedents (4.6%) had a history of cancer. Significantly more decedents with a history of cancer (versus without) were male, non‐Hispanic white, married, veterans, and aged 55 or older (P <.001). Decedents with a history of cancer were more likely to die of suicide by firearm and less likely to die of suicide by suffocation compared to poisoning. In matched case analyses controlling for demographic and recent circumstances, fewer decedents with a history of cancer had mental health problems, history of suicide attempts, alcohol use problems, intimate partner problems, financial problems, job problems, and recent crisis. Conclusions Findings highlight the potential to identify high‐risk populations for suicide prevention in clinical practice.
... Furthermore, differences in suicide risk between those with various acquired and congenital physical disabilities have not been examined. Individuals who acquired a physical injury have reported financial and emotional difficulties [38], which are correlates of suicide [39,40]. Those with congenital or genetic conditions were less likely to report past-year suicidal ideation than those with acquired conditions; however, this research was not limited to those with physical disabilities [8]. ...
... Similarly, social risk factors are associated with higher rates of suicide in older men, which suggests that more aggressive screening and treatment may be required. [21][22][23] The extent to which evidence about sex and gender is integrated into clinical practice guidelines for diagnosis and management of diseases remains unknown. We conducted a systematic review to investigate the integration of sex and gender evidence into Canadian clinical practice guidelines published between 2013 and 2015 for noncommunicable health conditions. ...
Background: The importance of sex and gender in the diagnosis and management of health conditions is well established, but the extent to which this evidence is integrated into clinical practice guidelines remains unknown. We aimed to determine the proportion of Canadian clinical practice guidelines that integrate evidence on sex and gender considerations. Methods: We searched the Canadian Medical Association's CPG Infobase, PubMed, all provincial/territorial websites and websites of professional organizations for English- and French-language Canadian clinical practice guidelines published between January 2013 and June 2015 on selected conditions identified as priorities by policy-makers and practitioners. Citations and text were searched electronically using keyword terms related to sex and gender. Three investigators independently analyzed and categorized the content of text-positive clinical practice guidelines based on clinical relevance for practitioners. Results: Of the 118 clinical practice guidelines that met the inclusion criteria, 79 (66.9%) were text-positive for sex and/or gender keywords; 8 (10%) of the 79 used the keywords only in relation to pregnancy. Of the remaining 71 guidelines, 25 (35%) contained sex-related diagnostic or management recommendations. An additional 5 (7%) contained recommendations for sex-specific laboratory reference values, 29 (41%) referred to differences in epidemiologic features or risk factors only, and 12 (17%) contained nonrelevant mentions of search keywords. Twenty-five (35%) of the text-positive guidelines used the terms "sex" and/or "gender" correctly. Interpretation: Recommendations related to sex and gender are inconsistently reported in Canadian clinical practice guidelines. Guidelines such as the Sex and Gender Equity in Research guidelines may help inform the meaningful inclusion of sex and gender evidence in the development of clinical practice guidelines.
Objective This rapid review aimed to understand the rates of suicidal ideation and behaviours in men who are separated from intimate relationships, the co-occurrence of risk factors, and the effectiveness of suicide prevention interventions for them in order to inform future suicide prevention efforts. Method The review method followed a streamlined systematic review process which facilitates an expedited review of the evidence related to the review questions. We searched three academic databases (Cochrane, Medline and PsycINFO) for peer-reviewed articles published between 2010 and 2019 in English using keywords related to men who are separated from an intimate relationship; suicidal thoughts, attempts and deaths; suicide rates; and suicide prevention interventions. Results Four systematic reviews and 22 papers featuring primary studies were included in the review relating to suicide rates and risk. No papers were identified relating to the effectiveness of suicide prevention interventions for this group. The evidence base was rated as good. The findings suggest that men who are separated from an intimate relationship are at higher risk of suicide. Discussion The review identified an increased risk of suicide among men who are separated, but no evidence about the effectiveness of suicide prevention interventions for them. More work is needed to unpack the interplay between personal and sociodemographic factors and the risk of suicide for separated men in order to inform suicide prevention efforts with these men.
Suicidality-specific diagnoses have been proposed recently, but suicidologists are only just beginning to evaluate their merits. To advance this discussion, I introduce the term suicidal syndrome to describe the underlying entity, present a rationale for why a formal diagnosis is necessary, define the major features of the syndrome, and show how the syndrome could meet the requirements for new diagnostic candidates used in the development of the DSM-5. Against this backdrop, I examine common objections to a suicidality-specific diagnosis. Finally, I discuss several challenges with the creation of new diagnostic entities as they apply to suicidal syndrome.
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Background: To better understand and prevent suicide and homicide, the National Center for Injury Prevention and Control of the US Centers for Disease Control and Prevention launched the National Violent Death Reporting System (NVDRS) in six states in 2002. As of 2018, the NVDRS has been expanded to include all 50 states, the District of Columbia and Puerto Rico. The purpose of this review was to assess the research utility of the NVDRS based on studies indexed in major bibliographical databases. Methods: We performed a scoping review of published studies that were based on data from the NVDRS, identified by searching six electronic databases: PubMed, EMBASE, Google Scholar, OVID, Scopus, and Web of Science. We examined the time trend of annual NVDRS-based research output, generated a word cloud using the keywords listed in the publications, and mapped the knowledge domains covered by NVDRS-based studies. Results: Our review included a total of 150 studies published between 2005 and 2018. There was a marked increase in the annual number of NVDRS-based publications, with 120 (80.0%) of the 150 studies published between 2011 and 2018. Overall, 104 (69.3%) studies focused on suicide and 39 (26.0%) on homicide. Of the included studies, 100 (66.7%) were descriptive epidemiology, 31 (20.7%) were risk factor analyses, 9 (6.0%) were evaluations, 7 (4.7%) were trend analyses, and 4 (2.7%) were data quality assessments. Knowledge domain mapping identified two major clusters of studies, one on suicide and the other on homicide. The cluster on suicide was commonly linked to "circumstance," "alcohol" and "substance abuse" and the cluster on homicide was commonly linked to "firearm," "injury," and "gang." The two clusters were interlinked to overlapping networks of keywords, such as "firearm" and "mental health problem." Conclusions: Research utility of the NVDRS has increased considerably in recent years. Studies based on data from the NVDRS are clustered in two knowledge domains - suicide and homicide. The vast potential of the NVDRS for violence research and prevention remains to be fully exploited.
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A grounded theory of academic change is offered as an alternative to existing models of academic change. The constant comparative method, an inductive method of discovering theory, is elaborated and applied to the emergence of the theory. The theory is then presented through a series of theoretical statements which relate a series of primarily political concepts and processes. Briefly, the theory identifies several major processes which link pressures for change and a policy decision to change: conflict and interest group pressures followed by power exertion, administrative intervention, faculty leadership exercised through interest group advocacy, and compromises which are negotiated through administrative leadership. Finally, the theory is briefly discussed and compared with alternative models of change, including Baldridge's political model of academic change.
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Qualitative content analysis and thematic analysis are two commonly used approaches in data analysis of nursing research, but boundaries between the two have not been clearly specified. In other words, they are being used interchangeably and it seems difficult for the researcher to choose between them. In this respect, this paper describes and discusses the boundaries between qualitative content analysis and thematic analysis and presents implications to improve the consistency between the purpose of related studies and the method of data analyses. This is a discussion paper, comprising an analytical overview and discussion of the definitions, aims, philosophical background, data gathering, and analysis of content analysis and thematic analysis, and addressing their methodological subtleties. It is concluded that in spite of many similarities between the approaches, including cutting across data and searching for patterns and themes, their main difference lies in the opportunity for quantification of data. It means that measuring the frequency of different categories and themes is possible in content analysis with caution as a proxy for significance.
Life events experienced in the six months before a suicide attempt were compared with events for two matched control groups. Suicide attempters reported four times as many events as were reported by subjects from the general population and 11/2 times as many as were reported by depressed patients prior to depressive onset. A substantial peaking of events occurred in the month before the attempt. The excess over general population controls spanned most types of event. That over depressive onset was more selective, and it involved events with threatening implications, including undesirable events, those rated as stressful, and those outside the respondent's control. Unlike depression, suicide attempts were preceded equally by entrances and exits in the social field. Overall, the findings indicate a strong and immediate relationship between suicide attempts and life events.
Suicide and suicidal behaviors are complex, heterogeneous phenomena that are thought to result from the interactions among distal factors increasing predisposition and proximal factors acting as precipitants. Epigenetic factors are likely to act both distally and proximally. Aspirational Goal 1 aims to find clear targets for suicide and suicidal behavior intervention through greater understanding of the interplay among the biological, psychological, and social risk and protective factors associated with suicide. This paper discusses Aspirational Goal 1, focusing on the research pathway related to epigenetics, suicide, and suicidal behaviors. Current knowledge on epigenetic factors associated with suicide and suicidal behaviors is reviewed and avenues for future research are discussed. Epigenetic factors are a promising area of further investigation in the understanding of suicide and suicidal behaviors and may hold clues to identifying targets or avenues for intervention.
Personality traits were examined using the NEO Five-Factor Inventory-Revised in an Australian psychological autopsy study involving 259 suicide deaths and 181 sudden death controls aged 35 years and over. Interviews included the Structured Clinical Interview for DSM-IV to determine the presence of psychiatric disorder. Personality traits of suicide deaths differed significantly from those of controls, scoring higher in the Neuroticism and Openness to Experience domains and lower on the Agreeableness and Extraversion domains. These findings varied with the presence of psychiatric disorder and by age. High Neuroticism scores were the most consistent finding in people who died by suicide, although these scores decreased in older suicides.