Stressful life events in suicide attempts and completed suicides

The role of stressful life events in suicide attempts and completed suicides has been a key area of study in the epidemiology of mental disorders.  Although suicidal behavior often occurs in the context of acute and chronic stressor, this does not prove a causal link.  We all could probably report serious life stressors throughout out lives and these could be interpreted as a reason for suicidal behavior.  So these associations could simply be a coincidence and not have anything to do with suicidal behavior.

A recent analysis of the WHO (World Health Organization) World Mental Health Surveys attempts to shed some light on this issue.  This study focused on traumatic life events, a subset of life stressors that are associated with the development of PTSD.  The traumatic events studied included:

  1. natural and man-made disasters
  2. combat, war and refugee experiences
  3. sexual and interpersonal violence
  4. witnessing or perpetrating violence
  5. death or trauma to a loved one

These more serious stressful life events provide a opportunity focus on events everyone would agree as significant.  The authors then looked at five lifetime categories related to suicide:

  1. suicide ideation
  2. suicide attempt
  3. suicide planning in those with ideation
  4. suicide attempt in those with a suicide plan
  5. suicide attempt in those without a plan

The most common traumatic events reported by respondents across the 20 country survey included: death of a loved one (30.5%), followed by witnessing violence (21.8%), interpersonal violence (18.8%), accidents (17.7%), exposure to war (16.2%) and trauma to a loved one (12.5%).

The authors of the study perform complex analysis of the individual and cumulative effects of traumatic events.  The key findings summarized by these analyses include:

  • experiencing interpersonal or sexual violence appeared to have the strongest effect on suicidal ideation and suicide attempt
  • suicidal ideation and attempts had a dose-response effect with traumatic experiences–the more number of experiences, the higher the risk although this effect plateaued after experiencing about 4 events
  • traumatic effects had limited effect on the progression from suicidal ideation to a suicide attempt
  • effects of traumatic events occurred across low-, middle- and high income countries
  • it was estimated that elimination of traumatic life events could reduce population suicide ideation by 15% and suicide attempts by 22%

The study was not able to analyze the effect on the most important variable–completed suicide.  This would add significant weight to attributing a link between traumatic life events.  Nevertheless, this study provides additional insight into stressful life events and suicide ideation and plan.  Traumatic events appear to be important although playing a relatively minor role.  Presence of a serious mental disorder, i.e. major depression, bipolar disorder, substance abuse, schizophrenia, severe personality disorder continues to be the most important risk factor for suicide.

William Yates is a family physician who blogs at Brain Posts.

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