By Frederik Løgstrup Magnusson and Christian Ulrich Eriksen
The global state of suicide
In 2016, self-harm was the cause of 817,100 deaths globally across all age groups, a decrease of 3,000 from 2006. This excludes traffic injuries and other unintentional injuries (Naghavi et al., 2007). An estimated 10-20 million suicide attempts occur every year (Hendin, 2008; Naghavi et al., 2007). As such, suicide is a major global health issue that needs to be addressed in prevention efforts. Traditional approaches to suicide prevention include treatment of mental illness, restricting access to lethal means of suicide, etc. But why are social factors and societal structures rarely included in the discussion about suicide or the prevention thereof? It is known that the risk factors for suicide are multiple, and the primary risk factors include mental disorders, past suicide attempts, social isolation, family conflict, unemployment and somatic illness (Van Orden et al., 2010), with a prior suicide attempt being the most important factor for suicide (World Health Organization, 2014).
As one of the most tragic human events to occur, suicide is undeniably interlinked with mental health. By a huge margin, 90 percent, suicide victims also suffer from mental disorders (Cavanagh et al., 2003), and it is not implausible to think that the remaining ten percent suffer from subclinical afflictions. But even though mental illness is present in all or nearly all of completed suicides, being a major risk factor for engaging in suicidal behavior, it does not exclude other factors from playing an important role. Mental illnesses have complex etiologies with multiple genetic and environmental factors influencing the development of these diseases. It is plausible that social factors and societal structures contribute to the burden of mental illness and thus, indirectly, to suicidal behavior.
On a structural level, factors such as inequality have been linked with suicide rates. A study from Brazil, comparing suicide rates to the Gini Index, a measure of income inequality, within municipalities, suggested that higher inequality was connected with higher suicide rate, with each 10-point decrease in the Gini Index predicting a 5.5 percent decrease in the suicide rate. The Gini Index measures income inequality on a scale from 0 to 100, with 0 being the most equal income distribution and 100 being the most unequal (Machado et al., 2015).
In the US, an increase in the suicide rate has been observed from 2006 to 2014, and in the same period, an overall increase in suicide attempts has taken place. This observed increase in suicide attempts has been found to primarily affect younger adults with lower levels of formal education, a history of violence, and those with a range of mental disorders, such as depression and anxiety (Olfson et al., 2017).
In a WHO study including more than 100,000 respondents from 21 countries, the researchers did not find a large difference in the prevalence of suicidal ideation, planning or attempt between developed and developing countries, but they did find that people with suicidal ideation would more often develop a plan to attempt or actually attempt suicide in developing countries compared to developed. On the other hand, unplanned suicide attempts made up a larger proportion of all attempts in developed countries. The same researchers also found that women were more likely to exhibit suicidal ideation and, in developing countries, to plan suicide attempts. Unemployment was shown to predict planned suicide attempts in both developed and developing countries (Borges et al., 2010)
Stigma, marginalization and belongingness
Marginalized and discriminated groups in society experience the highest levels of suicide. The stigmatization that these groups face from society can both directly influence the risk of suicide, by delaying or preventing treatment for suicidal thoughts and behavior (Pompili et al., 2003), but also indirectly through people belonging to these marginalized or discriminated groups internalizing the negative beliefs that the wider public holds against them. This phenomenon is called self-stigma, and it leads to shame, hopelessness, social isolation, and low self-esteem (Oexle et al., 2016). Social isolation predicts suicidal ideation, attempts and lethal suicides very reliably, while strong social connections, such as marriage, having children, and a large number of family and friends is a predictor of the opposite (Conwell, 1997; Dervic et al., 2008; Trout, 1980; Van Orden et al., 2008).
One group that can face stigmatization is people with mental illnesses. We could speculate that if the risk of receiving a damning stigma when seeking mental health care is too high, it may be better for a sufferer of depression or other mental illnesses to forego care-seeking, in terms of reducing the risk of suicide. Stigmatization and the resulting marginalization may exacerbate this risk, rather than reduce it.
A prominent theory of suicide and suicidal behavior is the Interpersonal Theory of Suicide. The primary thesis of the theory is that lacking a sense of belongingness and perceiving oneself as a burden are the major psychological factors that ultimately will lead people to engage in suicidal behavior. Being lonely and not having reciprocally-caring relationships leads to a sense of thwarted belongingness. According to Van Orden et al. (2010), this represents a state, rather than a stable trait, which is affected by intra- and interpersonal factors. In other words, thwarted belongingness, which can lead to suicide, is caused by the social network a person is situated in, the person’s mode of interpreting the world, i.e. whether he tends to believe he is being rejected, and his emotional state, working together.
One example of not experiencing reciprocally caring relationships is social control, which is the overregulation of behavior. The role of social control was investigated in a study in Iran, where it was found that the provinces with lower levels of female education, female labor force participation, and urbanization had the highest rates of female suicide (Aliverdinia and Pridemore, 2009). This finding stresses the fact that caring interpersonal relationships are crucial for mental health and wellbeing, and including work on culture and gender in suicide prevention activities could be a feasible way to move forward.
In summary, while we recognize the interlinkages with psychopathology and the salutary effects of various behavioral and pharmacological interventions, we argue that it is one-sided to see suicidal behavior as a problem merely rooted in psychopathology. Rather, social issues within a society or community contribute to the prevalence of both suicidal ideation, planning, and attempts.
We believe that the impact of economic inequality, stigmatization, marginalization, and social control should be taken into account when planning and implementing measures to prevent suicide. While absolute wealth appears to be less important when comparing countries, inequality within countries and regions seems to have an impact on the prevalence of suicide. Likewise, stigmatization, marginalization and social control are detrimental to mental health and a cause of attempted suicide.
As such, suicide cannot be thought of solely as the result of a lack of access to high quality mental health care, though that may play an important role as well. Governments and policy makers must consider social security and social services, when they seek to mitigate the risk, and not name pathology or rash decisions as the root cause of every suicide. Likewise, stigmatization and marginalization must be addressed, and tolerance in communities and society must win out, if suicide is to be addressed successfully.
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