Advancing Suicide Research E-Book

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 796

Veröffentlichungsjahr: 2021

Beschreibung

In this book leading researchers provide an overview of current best practices in the conduct of suicide research. They describe quantitative, qualitative, and mixed-methods approaches in suicide-prevention research from a public health perspective. In addition, other aspects that are crucial to effective suicide research are examined, including definitional issues, historical background, and ethical aspects. The clearly written chapters include both theoretical and practical information along with specific examples from different areas of suicide research and prevention. This volume is ideal for researchers, students, and academics interested in suicide research, as well as policy makers, clinicians, and other practitioners.

Leseprobe

Kairi Kõlves, Merike Sisask, Peeter Värnik, Airi Värnik, and Diego De Leo (Eds.)

Advancing Suicide Research

Library of Congress Cataloging in Publicationinformation for the print version of this book is available via the Library of Congress Marc Database under the LC Control Number 2020945109

Library and Archives Canada Cataloguing in Publication

Title: Advancing suicide research / Kairi Kõlves, Merike Sisask, Peeter Värnik, Airi Värnik, and

Diego De Leo (Eds.).

Names: Kõlves, Kairi, editor. | Sisask, Merike, editor. | Värnik, Peeter, editor. | Värnik, Airi,

editor. | De Leo, Diego, 1951- editor.

Description: Includes bibliographical references and index.

Identifiers: Canadiana (print) 20200328220 | Canadiana (ebook) 20200328301 | ISBN 9780889375598

(hardcover) | ISBN 9781616765590 (PDF) | ISBN 9781613345597 (EPUB)

Subjects: LCSH: Suicide—Research. | LCSH: Suicide—Prevention.

Classification: LCC HV6545 .A38 2020 | DDC 362.28—dc23

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|V|Dedication

Allison Milner (1983–2019)

This book is dedicated to the memory of Associate Professor Allison Milner. She was a passionate and gifted academic who was an inspiration to us all. She devoted her academic career to helping those most in need through her research in mental health and suicide prevention. Her untimely death in an accident is a tragic loss. We are grateful for her contribution to the book.

Allison Joy Milner (May 1, 1983 – Aug 12, 2019) was a social epidemiologist focusing on workplace mental health and suicide prevention. Her research career started at the Australian Institute for Suicide Research and Prevention at Griffith University working on the Queensland Suicide Register and the World Health Organization’s project Suicide in At Risk Territories (the WHO/START study). She continued her doctoral studies on suicide and globalization and was awarded a PhD by Griffith University in 2010. Her postdoctoral studies brought her to the University of Melbourne in 2012, where she finished a master’s degree in epidemiology. In 2015, she was appointed as the Deputy Director of the Work, Health and Wellbeing Unit at Deakin University. She became Associate Professor and Deputy Head of the Disability and Health Unit at the Centre for Health Equity, Melbourne School of Population and Global Health at the University of Melbourne in 2018.

Despite her tragically short life, Allison was a very productive academic, publishing over 170 peer-reviewed papers (Scopus), numerous book chapters and reports. Allison was the National Academic Director of Mates in Construction, Co-Chair of the IASP Special Interest Group on Suicide in the Workplace, and a member of different boards and committees. Allison was a recipient of a number of awards including, the National Emerging New Researcher Award from Suicide Prevention Australia in 2011; a Tall Poppy Science Award in 2014; the Vice Chancellor’s Award for Excellence in Research (Deakin University) in 2015; the Griffith University Outstanding Higher Degree Research Health Alumnus award in 2017.

She was a devoted wife to Rohan and mother to Byron and Theo, and a dear friend and colleague to many of us, and she is greatly missed.

|VI|Acknowledgments

We are grateful to Dr. Victoria Ross and Dr. Damian Shaw-Williams for their help with language editing.

Kairi Kõlves’ editing and writing contribution to this book was supported by the Academic Studies Program of Griffith University, Brisbane, Australia. Merike Sisask was supported by the Estonian Research Council (Grant PRG71 “Contemporary Demographic Developments in Estonia: In Search of Pathways Towards a More Sustainable Society”).

Contents

Acknowledgments

Foreword

Preface

Chapter 1 The Roots of Suicide Research: From Historical Underpinnings to Frameworks for Modern Suicide Research

Chapter 2 Definitions in Suicide Research

Chapter 3 Public Health Approach to Suicide Research

Chapter 4 Ethical Aspects of Suicide Research

Chapter 5 Measures in Suicide Research

Chapter 6 Observational Studies in Suicide Research

Chapter 7 Intervention Studies in Suicide Research

Chapter 8 Data Linkage and Studies of Suicidal Behavior

Chapter 9 The Words to Say It – Qualitative Suicide Research

Chapter 10 Mixed Methods in Suicide Research

Chapter 11 Psychological Autopsy – A Tool in Suicide Research

Chapter 12 Pilot and Feasibility Studies in Suicide Research

Chapter 13 Systematic Reviews and Meta-Analyses in Suicide Prevention Research

Chapter 14 Evaluating Suicide Prevention Activities

Chapter 15 Applying a Health Economics Lens to Suicide Research

Chapter 16 Technology and the Future of Suicide Prevention

Contributors

Subject Index

Peer Commentaries

|IX|Foreword

Suicide is a serious public health issue causing about 800,000 deaths globally, every year. Most suicides can be prevented with some evidence-based interventions, both at the single health care practitioner level and at the level of national policy.

High-quality data on suicide and suicidal behavior is lacking. According to the World Health Organization (WHO), only 80 countries have good-quality registered data on suicides that can be used to estimate suicide rates. More countries should invest in starting to register suicidal behavior and share their data.

Suicide is an enigmatic behavior. Most living creatures carry a genetic instinct for survival even in highly unfavorable circumstances. For most nonsuicidal people, it is hard to understand the extreme mental pain that causes a person to take their own life. The data we have today seem to indicate that suicidal behavior is a multifactorial trait, and death by suicide is an acute event that occurs in psychologically and biologically vulnerable people, usually suffering from chronic mental pain. In the fight with this global epidemic, we need a considerable international effort, good science, and an evidence-based approach by multidisciplinary teams. Only an evidence-based approach can lead to effective and safe interventions.

Advancing Suicide Research is the most comprehensive text in the field of suicide research methods. A group of leading researchers in suicidology, Kairi Kõlves, Merike Sisask, Peeter Värnik, Airi Värnik, and Diego De Leo, have joined together to present us with a reference book that describes every method used for suicide research. Focusing on quantitative, qualitative, and mixed methods approaches, the book covers everything a researcher in suicidology may need.

An important aspect of this book is the consolidation of definitions so that all of us are on the same page, as well as providing a complete list of ethical aspects for this sensitive area of research. The book covers most of the known measures of suicidal behavior, offering a reliable and valid tool that allows for data pooling from different locations and populations. It then goes on to cover observational studies, interventional studies, and linkage studies. Of great importance is its coverage of qualitative and mixed approaches. Sometimes the story of a single suicide victim can teach us a great deal and lead to new hypotheses. The book covers the whole spectrum of studies from case reports to meta-analyses. It ends with some strong chapters on prevention and postmortem studies and on technological advances.

This book will be of great interest for a wide range of readers, from students and junior PhD scientists, to experienced researchers who are familiar with and use only a single method and want to learn other methods. Also, policy makers, clinicians, and other practitioners interested in suicide research will find the text easy to read and understandable.

Prof. Gil Zalsman, MD, MHA, BSc

President of the International Academy for Suicide Research (IASR)

Director, Geha Mental Health Center and Adolescent Day Unit

Professor of Child Psychiatry, Tel Aviv University, Israel

|XI|Preface

Suicidal behavior has a significant global human toll. Despite differing levels of suicidality and circumstances among nations, in 2014 the World Health Organization led the global call for suicide prevention using a public health approach. Research is the underlying feature of the public health model in suicide prevention. It plays a vital role in improving our knowledge about suicidal behavior, and developing and evaluating suicide prevention interventions. To advance the quality of suicide research and prevention, this book focuses on conducting suicide research by presenting key concepts from the public health perspective. We are grateful that a wide range of experts working in suicide research have contributed their wisdom and knowledge it.

Before formulating research questions and considering the most suitable research designs and methods, it is important to contemplate the work in the field that has been completed to date. Chapter 1 does this, giving a brief summary of the historical contributions to modern suicide research. Considering different terminologies, Chapter 2 focuses on definitions and nomenclatures of suicidal behavior. Chapter 3 sets the scene for the use of a public health approach to suicide research to identify the patterns of suicidal behavior and explore risk and protective factors, as well as develop and evaluate interventions. Ethics is an important concern in conducting research, and ethical challenges in suicide research are addressed in detail in Chapter 4.

Epidemiology is the cornerstone of public health; the proper use of epidemiological measures and study designs is also central to the success of suicide research and prevention. Chapter 5 focuses on measures in suicide research, and that focus is continued in Chapters 6 and 7, which present the use of observational and intervention studies and discuss their strengths and weaknesses. Chapter 8 explores the potential use of data linkages as an alternative to conducting observation and intervention studies.

While epidemiology is positivistic by nature, utilizing quantitative methods, there is a growing need for qualitative methods in public health and health research more widely. This need has also grown in suicide research, as presented in Chapter 9. In addition, mixed methods designs incorporating both quantitative and qualitative methods have been welcomed in suicide research in the last decade and are discussed in Chapter 10.

Further, a number of other essential topics in suicide research are covered. Chapter 11 explores the use of a psychological autopsy as an important research tool since the 1950s. Chapter 12 addresses the need to test one’s methodology in the form of a feasibility or pilot study before conducting a large-scale study. Chapter 13 considers the need for systematic literature reviews and meta-analyses, with methodological issues being addressed in detail. Chapter 14 presents different approaches to designing evaluations in suicide prevention; Chapter 15 adds considerations from an economic perspective. The final chapter addresses new technologies and their application to the future of suicide research.

We hope that students, practitioners, and policy makers may find some valuable elements here to improve their knowledge, but also that academics working in the field may benefit from insights into methodology or concepts they have not utilized before.

Kairi Kõlves, Merike Sisask, Peeter Värnik, Airi Värnik, and Diego De Leo

|1|Chapter 1The Roots of Suicide Research

From Historical Underpinnings to Frameworks for Modern Suicide Research

Morton M. Silverman

Summary

This chapter will briefly summarize the historical contributions to our understanding of suicide and suicidal behaviors, with a focus on the last 3 centuries. Political, legal, and theological contributions have shaped our approaches to the investigation of suicidal behaviors, as have the contributions of emerging scientific methods and theories. Key themes, findings, and lines of research over the centuries will be compared, emphasizing their influences on the foundations and development of modern suicide research. Various lines of research and scientific paradigms have contributed to many aspects of the understanding and prevention of suicidal behaviors, including epidemiology, risk detection, concepts of clinical course, and approaches to treatment, evaluation, and follow-up.

Suicide and self-destructive behaviors have been chronicled as far back as the Old Testament. However, scientific approaches to understanding suicide and its many vicissitudes are a much later development. The history of suicide and suicide-related behaviors, as well as the early investigations into their etiology, pathogenesis, and expression, are briefly summarized below. The scientific study of suicide began at the end of the 19th century, but has only increased exponentially in the last 60 years. Furthermore, there has been an explosion of meta-analyses of studies that focus on all forms of suicide-related thoughts and behaviors, including the components used for identification and assessment, the efficacy of interventions, and the methodologies to study different aspects of suicide-related behaviors.

No one risk factor or set of risk factors can explain why a particular individual will die by suicide (Franklin et al., 2017). No one theory can explain the full range of self-injurious or suicidal behaviors. No one individual approach will be sufficient in preventing death by suicide. Understanding its development, expression, and resolution cannot be reduced to a small set of variables. No single scientific discipline can address the complex challenge of understanding the risk for suicidal behaviors, as suicide is the end product of a complex interplay of neurobiological, psychological, and social processes (O’Connor & Portzky, 2018b). As a behavior, suicide-related phenomena have precursors, but just as suicide-related behaviors have different manifestations and expressions, so do the precursors (Robinson & Pirkis, 2014).

|2|Foundations of Suicide Research

Suicide research owes its foundation and approaches to many related research disciplines and associated investigations, including psychology, psychiatry, medicine, sociology, theology, social work, public health, epidemiology, traditional statistics, and implementation science. The range of research areas includes, but is not limited to, risk assessment studies (assessment and classification of suicide risk); epidemiological studies (rates, risk factors, and protective factors); intervention studies (general intervention issues and methods, practice guidelines, efficacy of universal interventions, efficacy of selective interventions, and efficacy of indicated interventions); evaluation of policies, programs, and services; biological research (neurobiology and genetics); social science (social forces and economic determinants); media studies; nomenclature and classification studies; implementation science; etc.

This brief overview of the history of suicide owes a great deal to the published works of scholars who have extensively studied and critiqued available treatises and historical documents (Anderson, 1987; Berrios & Mohanna, 1990; Goldney & Schioldann, 2002; MacDonald & Murphy, 1990; Minois, 1995/1999; Murray, 1998; Tondo, 2014; van Hooff, 2000). The interested reader is encouraged to access these texts and chapters for a much more detailed and richer understanding of the history of investigations and writings about suicide, especially in Western cultures. In this brief overview of the historical underpinnings for modern suicide research, the main focus is on the publications and philosophical perspectives that specifically relate to death by suicide before 1900 (Minois, 1995/1999).

A Brief History of Suicide in Antiquity and Western Cultures up to 1800

References to suicide are found in the Old Testament of the Bible and appear in almost every cultures’ oral and written histories. However, the purpose of this brief review is to highlight some key events that have served as the impetus for the later development of the field of suicidology, and, in particular, the development and evolution of suicide research. Hence, the selection of time periods and countries is rather eclectic.

From as far back as ancient Greece, suicide was not considered acceptable. From the 4th century BC, suicidal decedents were usually denied burial or traditional preburial preparation or cremation, and were considered to have committed a grievously antisocial act. Only those deaths by suicides in which it was possible to find a sufficient reason for self-destruction were deemed comprehensible (e.g., heroism, love-rejection, or serious or painful illness). The standard of being understandable was considered the key to assessing suicide to be a justified action (Tondo, 2014). Judgments concerning suicide changed when ancient Greek philosophers became interested in the primacy of reason over the emotions. They based their prohibition of suicide primarily based on its incomprehensibility or irrationality, and it was viewed as an aberration against the natural order to survive. Emotion-driven behaviors became a focus of attention and resulted in laws and customs imposing limits on the expression of such behaviors. To this day, the quest to remains understand and explain self-destructive behaviors from a rational and/or emotional perspective.

Of note is the fact that Plato (424–347 BC) was opposed to suicide, because he claimed that men are social individuals with a responsibility to others. Aristotle (384–322 BC) |3|disapproved of suicide because he saw it as a transgression against a civic duty and as an act of cowardice. Here we see the beginnings of a sociological perspective to explain suicide.

The two prominent philosophical schools of ancient Rome, Epicureanism and Stoicism, approved of suicide, but for different reasons. The Epicureans believed that the goal of man was the pursuit of happiness, and when this could not be achieved, life lost its purpose. The Stoics placed reason, virtue, and morality above pleasure and common interests, sometimes to the point of reaching a state of detachment and a lack of interest in life (Tondo, 2014).

In medieval England, laws against suicide were promulgated in AD 967, including the distinction maintained over the centuries between those who died by suicide when of sound mind and those who were insane. Suicide was not considered a sinful or criminal act in cases of insanity.

In Italy, Thomas Aquinas (1225–1274) condemned suicide because it was an act against nature and against the benevolence we should have toward ourselves, and he therefore considered it to be a mortal sin. It was also seen as an insult against the community to which we belong and to which we have duties. Finally, it represents an act of defiance and rejection of the laws of God who gave us life and is the only one who may decide to take it back (Tondo, 2014).

During the Renaissance (14th–17th centuries), the growing interest in humanism resulted in frank admiration for suicide in which intellectuals found an implicit message of freedom. The Protestant Reformation stimulated growth of individual thinking and efforts to set aside the rules and rigidity of the Catholic Church, leading to a more liberal and questioning attitude toward suicide. Of note is that the Anglican clergyman John Donne (1572–1631), in his essay on the topic of violent death (published after his death, in 1647), wrote about the paradox that self-murder is not a sin against nature, and he justified the act of suicide. His perspective was that human nature was guided by rationality, and it could be considered appropriate to die by suicide and not contrary to reason. Furthermore, Donne argued that the Bible did not condemn suicide.

The French writer Michel Eyquem de Montaigne (1533–1592) wrote in his essays (1580) quite favorably about understanding the wish to die as a reasonable option. However, he did not encourage anyone to die by suicide. The English political philosopher Thomas Hobbes (1588–1679) saw suicide as a destructive act against natural law, which therefore should not be allowed. However, starting around 1600, attitudes in European legal systems toward suicide generally became less punitive.

The French philosopher Rene Descartes (1596–1650) argued against suicide from a pragmatic stance. For example, life is not always happy but often does offer consolations, and that good things may be even more frequent than the bad ones. He rejected the idea of sin and punishment with regard to the act of suicide. He also expressed doubts about the mental health of people who died by suicide (Minois, 1995/1999; Tondo, 2014). Another important French philosopher Voltaire (nom de plume for Francoise-Marie Arouet) (1694–1778) defended suicide in cases of extreme necessity.

The Scottish Enlightenment philosopher David Hume (1711–1776), in his Essays on Suicide and the Immortality of the Soul (1755) expressed a tolerant view of suicide, stating that suicide could not be seen as an offense against God, and that the commandant “Thou shalt not kill” only applied to homicidal acts.

The philosopher Immanuel Kant (1724–1804), in his Metaphysics of Ethics (1786), reasoned that suicide is contrary to the love we owe to ourselves, and that suicide could not be considered an act of free choice.

The German philosopher Arthur Schopenhauer (1788–1860) wrote in his book On Suicide, in The World as Will and Representation (1818) that suicide did not offer a plausible escape from |4|difficulties intrinsic to an essentially irrational world. Those who died by suicide indeed wanted to live, but not on the terms that were offered; they needed to give up life because they were unable to give up the will to live better (Tondo, 2014).

Foundational Publications of Suicide Research Since the 1600s

The following is a summary of some of the foundational publications of suicide research. However, it is difficult, at best, to ascertain with any degree of certainty how influential any of these texts were on the manner in which suicide and suicidal behaviors were viewed by the general populations at the time, or the extent to which they influenced the thinking and actions of contemporaneous scientists, philosophers, and theologians.

The Englishman Robert Burton (1577–1640), in his Anatomy of Melancholy (1621), suggested that melancholy, a mental illness, was associated with suicide. He placed suicide in a nonreligious, more contemporary perspective and described conditions contributing to suicide, including agitation, hopelessness, and impulsivity. Of note, these very conditions are still being investigated today as they relate to suicide.

Goldney and Schioldann (2002) report that 18th- and 19th-century research specifically devoted to suicide is in fact “voluminous” (p. 13), with the identification of works published as early as 1744, 1767, and 1786. They note that much of the pre-Durkheim suicide research does not predominantly focus on a medical model, but gives due regard to identifying sociological factors, thus elevating sociological factors to an important role in effecting suicide.

A number of English clergymen published important works on suicide, including John Sym (1637), John Donne (1647), and John Adams (1700). By 1700, the term suicide had replaced self-murder and the subject began to interest the emerging scientific disciplines. By the 1700s, the majority of suicides were judged to be based on mental illness (Minois, 1995/1999). The English clergyman Charles Moore’s (1771–1826) two volumes titled A Full Inquiry into the Subject of Suicide (Moore, 1790) included observations about the association between gambling and suicide, genetic and hereditary factors, the role of stigma in distorting the counting of true cases, and the association between alcohol and suicide.

In 1788, the English physician William Rowley (1742–1806) wrote a medical treatise that incorporated religious, sociological, epidemiological, and psychological perspectives. He argued that suicide was an act against religion and so a crime against civility, because it deprived others of expected physical and mental services, and was immoral for being contrary to the individual’s duties to maintain relational ties. Although he seems to espouse a rather sociological perspective, he also introduced ideas concerning remote causes of suicide, which might include mental illness or bodily pain. In addition, he described proximate causes, including not being sufficiently brave or balanced as to endure misfortunes, or not being of sound mind. He concluded that when an individual contemplates suicide, his mental status must necessarily be compromised (Tondo, 2014).

Early medical views of suicide were attributed primarily to early 19th-century French authors, particularly Jean-Etienne Dominique Esquirol (1821; a student of Phillippe Pinel), although he incorporated both illness and social factors in his postulated causes of suicide (Berrios & Mohanna, 1990). In 1828, George Man Burrows, in his Commentaries on the Causes, Forms, Symptoms, and Treatment, Moral and Medical, of Insanity (Burrows, 1828), referred to |5|suicide as a feature of melancholia, and provided comparative data among a number of European cities.

In 1835, the Belgian mathematician and statistician-sociologist Adolphe Quetelet (1796–1874) published his book, translated as About Man and the Development of His faculties, or an Essay on Social Statistics (Quetelet, 1835/1968). This text ushered in the statistical study of suicide.

In 1840, the Englishman Forbes Winslow published The Anatomy of Suicide, which was based on statistical data. Pierre-Egiste Lisle (1856), another Frenchman, provided evidence that factors other than mental illness caused suicide, including debt, gambling, and marital discord.

In 1858, John Charles Bucknill and Daniel Hack Tuke published their famous textbook of English psychiatry, A Manual of Psychological Medicine containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of Insanity (Bucknill & Tuke, 1858). References to suicide included a classification of psychiatric illnesses; a discussion of modes of death; and the influence on suicide of age, sex, marriage, and the seasons; as well as the possibility of hereditary transmission.

In Australia, George Stephen (1874) published a review of suicide in the state of Victoria. Although legalistic and moralistic, he also incorporated sociological and mental illness factors in his comments. The Italian psychiatrist Enrico Morselli (1852–1929) published his seminal work translated as Suicide. Essay of Moral Comparative Statistics (Morselli, 1879) (translated into English in 1881), considered by many at the time as the most important work of 19th-century suicidology. Although heavily reliant on statistics, it covered such topics as social influences, biological influences, psychological influences, and methods and places of suicide. In addition, it included analyses of age and suicide in different countries, education and suicide rates, and the relationship between mental illness and suicide.

In 1885, William Wynn Westcott, in England, published his book A Social Science Treatise. Suicide: Its History, Literature, Jurisprudence, Causation and Prevention (Westcott, 1885). As the title suggests, it covers a wide range of topics, including rates and means of suicide, its causes, the effect of urban and rural life, the influence of mental illnesses, and the effects of physical illness and hereditary factors. He noted that most suicide studies were dependent on statistics, to the neglect of research into mental states and emotions. Nevertheless, he regarded suicide as a social problem.

Two separate reviews published in 1892 by Daniel Hack Tuke and George H. Savage, represent a rather sophisticated analysis of factors contributing to suicide at the time, prior to the publication of Emile Durkheim’s famous Le Suicide in 1897 (Goldney & Schioldann, 2002). These two reviews appeared in Tuke’s Dictionary of Psychological Medicine, published in 1892 (Tuke, 1892). Tuke and Savage were psychiatrists, and their perspective was medical (psychiatric). Tuke’s treatise focuses on the history, epidemiology, and etiology of suicide. Savage’s treatise is psychiatric in perspective.

Emile Durkheim (1858–1917) is often considered to be the founder of scientific suicide research, following the English translation in 1951 of his sociological treatise, Le Suicide: Etude de Sociologie, originally published in 1897 (Durkheim, 1897/1951). Durkheim’s focus was on sociology, not psychology. He believed that the individual’s relationship to society was the core dynamic in understanding deaths by suicides. As stated by Berman (2002), “He did not deny that psychological conditions played a role as determinants of individual suicides, but, as they were not readily generalizable, he did not believe they affected suicide rates” (p. 9).

Scientific suicide research in the second half of the 20th century, and well into the 21st, is notable for its references to Durkheim’s methodology and the almost obligatory comparisons |6|of any new findings to his original typology. Furthermore, since the publication of Le Suicide, there have been many articles and books written about Durkheim and his theories – both positive and negative. Durkheim lived in 19th- and early 20th-century France, where the meaning or importance of risk factors he studied (e.g., divorce and religious affiliation) differed from that of secularized, modern, Western societies as we experience them today. Nevertheless, his sociological and epidemiological approach to understanding suicide provided the foundation for further research in the 20th & 21st centuries.

As discussed by Bille-Brahe (2000), Durkheim concluded that

while the individual suicide seems to be the result of individual factors and circumstances, the frequency of suicide is nevertheless determined by the moral and psychological climate in the society in question. This means that the variations in the frequency of suicide can only be explained by the fact that certain societal conditions enhance or discourage the propensity to react to problems and pain, not by trying to remove the problems and the pain, but by removing oneself…. In the opinion of Durkheim, man is first and foremost a social being, who has survived through history by living and collaborating with his fellow human beings. (Bille-Brahe, 2000, p. 195)

The feelings of belongingness and social integration are contrasted with the need for autonomy and the attainment of individual wishes and goals (i.e., integration vs. disintegration). As is evident from a 21st-century perspective, such themes have remained grist for the mill in suicide research.

Although there do not appear to be any books devoted solely to suicide published in the US in the 19th century, Motto (1993) published a comprehensive review of 19th-century reports of suicide that appeared in the American Journal of Insanity, beginning in 1845. Amariah Brigham, the editor of the journal, commented in his first editorial, on the probable underreporting of suicides, as well as making reference to possible biological factors contributing to suicide. In 1849, Brigham commented in the journal, on familial and genetic factors in suicide. In 1877, John E. Tyler reported that members of the New England Psychological Society emphasized the importance of melancholia as contributing to suicide.

As summarized by van Hooff (2000), “Suicide became the mortal sin of self-murder in [early] Christian doctrine. This paradigm was challenged by Renaissance thinking and refined by Christian reformers, to be fundamentally rejected by the Enlightenment” (p. 122). During the 19th century, the prevailing attitude in Western culture shifted from the old ideas of suicide being a sin or a crime (and therefore punishable by law), to seeing suicide as an understandable behavior associated with an illness or with an extreme life condition. As van Hooff (2000) states,

No longer was a suicide regarded by the public as a sinner but as a sufferer…. No longer was suicide regarded as a heroic act of free will or as a mortal sin, but as a disease. The interest in soul and society was the result of the anxious awareness that modern man lived in an unnatural habitat. No longer had he his place in a close network formed by family, village, and church, but he got lost in huge cities. (van Hooff, 2000, p. 120)

It is important to remember that at approximately the same time, both the fields of psychology and sociology were developing as valid scientific specialties.

In the 20th century, these two understandings (i.e., illness vs. extreme life condition) evolved into distinct research approaches, one focusing on social determinants of suicide (e.g., environmental factors) and the other on psychological-medical determinants (e.g., mental |7|illnesses). In the 21st century, new technologies, methodologies, statistical tools, theories, and approaches to understanding the etiology and pathogenesis of what makes people suicidal, have all led to a virtual explosion of suicide research and their applications for the treatment and prevention of those at-risk for suicide and suicide-related behaviors.

Brief Overview of Modern Suicide Research Since the 1950s

It is a challenging task to present a comprehensive overview of modern suicide research in a single chapter. In the attempt to place some limits on this survey of relevant suicide research as it informs our current efforts, it has been decided to look exclusively at the major English-language research studies beginning in the 1950s up to the present. Needless to say, any topical list would be somewhat arbitrary and idiosyncratic to one reading of the suicide research in the last 70 years. Inasmuch as suicide and suicide-related behaviors are multidetermined and multifactorial, the research study of these behaviors has taken many shapes and forms. Suicide research, by its very nature, is interdisciplinary and multifaceted. In attempting to provide a broad-brush landscape of suicide research by topics or themes, it is inevitable that there is some redundancy and overlap.

The worldwide increased attention to suicide and suicide-related behaviors since the 1950s has resulted in an impressive expansion in suicide-related research, which has occurred on all fronts, including psychiatry, psychology, social sciences, biology, and genetics, to name but a few major research endeavors. There has been a greater focus on risk in specific subgroups, defined according to demographic and diagnostic categories. With the recognition that risk factors for suicide and suicide-related behaviors are often multidimensional, multidetermined, and multifactorial, research studies have expanded their scope in order to describe more precisely the characteristics of individuals at increased risk. There has been more attention to the development and evaluation of the effectiveness of psychological and pharmacological treatments for individuals who self-injure and to the complex and difficult challenges inherent in developing, implementing, and evaluating the effectiveness of preventive strategies at the national and local levels. The majority of the more recent suicide research has still been mainly conducted in Western countries, including European, North American, and Scandinavian countries, as well as Australia and New Zealand. Other regions of the world (e.g., Asian countries such as India, China, and Japan) have also added a great deal to the knowledge base of suicidology. Most of these studies have been quantitative (e.g., identifying risk factors, epidemiology, surveillance, and demographics), rather than qualitative (e.g., in-depth analysis of personal stories) or even clinical (e.g., intervention studies).

Even though there has been a virtual revolution in the quantity and quality of suicide research since the 1950s, the major question remains of why has there has not been a significant and sustained reduction in suicide rates worldwide. Part of the answer is that both suicide research and suicide prevention are difficult to conduct and evaluate. The incidence of suicide is low compared that of other illnesses, making it difficult to enroll sufficient numbers of at-risk subjects in research studies. Furthermore, from a clinical perspective, there is no accurate method to determine if any individual is going to die by suicide in the next day(s), week(s), month(s), or year(s). The potential risk for death by suicide has been shown to be correlated with a number of risk factors, which include signs and symptoms, distorted |8|cognitive states, and other high-risk behaviors. Yet there are distinct risk factor characteristics that differentiate between nonsuicidal self-injury, suicide ideations, suicide intent, suicide planning, suicide attempts, and death by suicide, making it difficult to develop algorithms for predicting suicide and/or suicide-related behaviors across populations. This is especially true when individuals present with clinically different expressions of suicidal thoughts and behaviors.

Although not always clearly stated, one of the overarching goals of all suicide research, if not the main goal, is to prevent suicide. To do so, the traditional approach has been to first understand and be able to identify the components of the suicidal process (either the chain of events that lead to suicidal behaviors, or the individual thoughts and behaviors that are often associated with suicidal behaviors), who is most likely to engage in these behaviors, and under what conditions (e.g., when, where, why). Once identified, these events and behaviors (i.e., precursors or causative agents) are targeted to be ameliorated, decreased, alleviated, amended, transformed, or eliminated in the at-risk population(s). This requires the development and implementation of interventions that are targeted to the identified factors in the targeted populations, based on an understanding of the etiologies and factors that lead to the expression of these events and behaviors. Once implemented, the interventions need to be evaluated for, at least, their validity, efficacy, reliability, fidelity, generalizability, and strength over time. If we are able to get to the point of declaring an intervention to be successful in the short-run (and, hopefully, in the long-run as well), we then have the challenge of disseminating the interventions in an efficient and effective manner, recognizing that translating and implementing interventions are affected by cultural, religious, and geopolitical differences.

Whether based on conventional research methodologies (e.g., randomized controlled trials) or on innovative methodologies, all approaches to the treatment of suicidal individuals and to the prevention of suicidal behaviors should be based on a thorough knowledge of causes and risk factors. A major contribution to our knowledge base comes from epidemiological studies in which the distribution of the occurrence of suicidal behaviors across the general population and the factors that influence this distribution are investigated. However, substantial methodological controversies and disparities have emerged when comparing epidemiological studies from different countries and regions of the world. There are differences in procedures of ascertainment of suicide and suicidal behaviors between and among countries – in no small part due to different national religious and cultural values placed on self-injurious behaviors, differences in terminologies and definitions, and differences in methods of collecting the data. Stigma regarding the reporting and documentation of suicidal behaviors and deaths remains a major challenge worldwide. Methods of investigating these injuries and deaths differ widely, as does the range of official ascertainment procedures and protocols.

Suicide research in the last 60–70 years has focused on its causes, precipitants, and potential methods of prevention and treatment, although much of the focus has been on risk factors (Franklin et al., 2017; Ribeiro et al., 2016). Different research traditions have approached this quest from their own unique perspectives. For example, biological studies have explored the neurobiological, biochemical, cognitive, behavioral, genetic, and epigenetic correlates of suicide in an effort to identify suicide-specific biomarkers. Such markers could help clinicians predict suicide risk, move the field toward evidence-based diagnosis, and provide concrete biological treatment targets (Sudol & Oquendo, 2016). A major goal of biological studies is to map the neural circuitry and the biological mechanisms involved in the etiology and expression of suicide and suicide-related behaviors.

|9|Relatively little is known about which interventions may be effective in reducing risk for suicide and suicide-related behaviors (Robinson et al., 2008), in particular among youths (Burns et al., 2005; Robinson et al., 2011). Previous research suggests that although youths receive a reasonable amount of research attention, the majority of studies have focused on epidemiological as opposed to intervention research. For example, although young people are a highly researched group in terms of published articles, most studies have been epidemiological in nature, reporting on rates of, and risk factors for, suicide, as opposed to reporting on the effectiveness of individual interventions (Robinson et al., 2008). This lack of emphasis on applied clinical research means that relatively little is known about what does and does not work in reducing suicide risk, which hampers both policy initiatives and preventive efforts more generally (Robinson & Pirkis, 2014).

Suicide research has slowly been moving from the identification and characterization of risk (risk factor research) at the micro and macro levels, to prediction of risk (screening, risk assessment), to tailored interventions (population and individual based), to prevention at the micro and macro levels (public education and media). In fact, the suicide research field really started at the macro level with the work of Durkheim (1897/1951) who attempted to answer the questions of who is at risk, when, and why. In the US, a statistical approach to identifying those at risk for suicide was undertaken by Louis I. Dublin & Bessie Bunzel in 1933 (Dublin & Bunzel, 1933). The micro level has advanced to include measuring variables at the interpersonal, intrapersonal, and intrapsychic domains. Clinical research has tended to focus on high-risk inpatient and outpatient clinical populations. One overriding goal of all of these research approaches is to answer the question, what is the pathogenesis of suicide? If causal relationships can be established, then there is the hope that tailored interventions can be developed, implemented, and evaluated that directly address these causal pathways.

However, the underpinnings of this approach are based on the medical model of identifying a pathogen for a specific illness, developing a way to measure its presence in humans, and then developing treatments to eradicate or diminish the virulence of the pathogen. The search has been for a single anatomical, physiological, biological and/or genetic, environmental, cultural, psychological, psychiatric, etc., pathogen that leads to the development and expression of suicide-related behaviors. If not a single pathogen, what combination or interchange of pathogens will lead to suicidal behaviors? What is the time course for such development? What triggers the expression of suicidal behaviors? Of course, adopting the medical model to the study of suicide suggests that we understand suicide as a disease, illness, or disorder that manifests itself in self-destructive behaviors. At this point in time, we best understand suicide-related behaviors as a comorbid condition, symptom, or expression of some other disorder, disease, or dysfunction (e.g., mental disorder, substance disorder) – not as a stand-alone illness. What complicates this scenario is that we have yet to clearly delineate the pathogenesis of many mental disorders that are often associated with suicidal behaviors, and our treatment of these associated disorders is often directed to addressing symptoms, not underlying pathogens.

In a critical analysis of the recent suicide research literature, Hjelmeland and Knizek (2016b) conclude that current mainstream suicide research almost unilaterally focuses on explanations of suicidal behaviors, very often using the linear cause-and-effect framework in the search for underlying causes of suicidal behaviors. The main framework for such studies relies on the biomedical model. “The field is dominated by repetitive risk factor studies, reductionist biological studies, and, to a lesser extent, intervention studies (e.g., randomized control studies, RCTs), with inherent limitations” (Hjelmeland & Knizek, 2016b, p. 696). They observe that studies focusing on explanations of suicidal behaviors most often use |10|“hypothetico-deductive or experimental methodologies,” usually employing quantitative approaches. From their perspective, the consequence is reductionism.

The problem with risk factor studies is that they do not tell us how the common risk factors are related to suicidal behavior, if indeed they are, or why it is that the vast majority of people suffering from one or some of them do not kill themselves. (Hjelmeland & Knizek, 2016b, p. 697)

They argue that to move the field forward, there needs to be an increase in studies focusing on understanding suicidal behaviors in different cultural contexts, necessitating a shift from quantitative to qualitative research studies. Such studies focus on how individuals interpret themselves, their actions, and their surroundings (Hjelmeland & Knizek, 2010).

There may be cultural differences in how important different factors are for people’s lives and hence for suicide and also individual differences both across and within cultural groups in terms of how a risk factor is perceived or experienced. It is not the risk factors per se, but the significance or meaning the individual assigns to them in their particular context that is decisive (Hjelmeland & Knizek, 2016a, p. 697).

There has been a growth in theories of suicidal ideation and behavior since the mid-1980s (O’Connor et al., 2016), beginning with Shneidman’s cubic model of suicide (Shneidman, 1985). Three recent research-based theories (i.e., the interpersonal psychological theory, the integrated motivational-volitional model, and the three-step theory) fit within the ideation-to-action framework (Joiner, 2005; Klonsky & May, 2015; O’Connor, 2011; O’Connor et al., 2016; O’Connor & Kirtley, 2018; O’Connor & Portzky, 2018a; Van Orden et al., 2010). This framework describes those theories which posit that the factors associated with suicidal ideation are distinct from those that govern behavioral reactions – that is, a suicide attempt and/or death by suicide (Klonsky et al., 2016; Klonsky et al., 2017; O’Connor & Nock, 2014). These new research-based theoretical developments have not only been important to enhance understanding of the complexities of the suicidal processes, but they are also forming the basis for the development of psychological and psychosocial interventions to reduce risk of suicide and self-harm.

Trends in Suicide Research Publications

It is instructive to look at the only three bibliometric studies of journals that exclusively publish suicide research. There are at least four key international journals that are devoted exclusively to the topic of suicide: Crisis: The Journal of Crisis Intervention and Suicide Prevention, Suicide and Life-Threatening Behavior (SLTB), Archives of Suicide Research (ASR), and Suicidology Online. Cardinal (2008) examined articles published in SLTB over a 30-year time frame, in three 5-year periods, namely, 1971–1975, 1984–1988, and 1997–2001, and proposed explanations for the trends and characteristics identified. Of particular note was that the percentage of the journal devoted to publication of research studies did not change over this time period (approximately 60 % of the journal’s pages), although the number of pages per issue increased. However, the proportion of research articles covering adolescents more than doubled, from 27.9 % in 1971–1975 to 60.8 % in 1997–2001 – but represented only 18.3 % of all research articles published between 1997–2001. The distribution in terms of the ages of participants does not mirror the distribution of suicide rates in the US or in many parts of the world. Cardinal (2008) suggests that the inordinate number of articles focusing on the adolescents perhaps had to do with a concern for potential years of life lost. Also, it could have |11|been a methodological issue, given that it was easier to access adolescents as a research group. Yet another reason may be purely emotional. Adolescents may be seen as the next generation, the heirs apparent, and their suicides may be perceived as being more tragic or more important than suicides in other age groups.

In contrast was the finding that the percentage of research articles in SLTB focusing on the old and very old dropped markedly between the periods of 1971–1974 and 1997–2001. With the demographic changes occurring over time in industrialized countries, especially the aging of the population, it is imperative that more future studies are focused on the old and very old age groups.

The gender distribution among SLTB articles is another interesting enigma. Men accounted for approximately 80 % of all deaths by suicide during this time period, but the proportion of research articles did not represent this fact. Research studies focusing solely on males dropped from 10.8 % in 1971–1975 to 7.7 % in 1997–2001, whereas research studies focusing solely on females remained fairly constant, at 5.4 % and 4.6 %, respectively.

In addition, this study found that the number of authors per article in SLTB increased dramatically over the years. This might be explained by the fact that suicide research had become increasingly complex, that a higher degree of specialization by researchers necessitated the establishment of multidisciplinary teams to pursue this research, and that cooperation among researchers was facilitated by new technologies.

Goldblatt et al. (2012) examined the abstracts of every paper published in Crisis, ASR, and SLTB, for the 5 years between 2006 and 2010, and they categorized each paper by subject. They found that the journals were similar with respect to subject allocation. Most papers dealt with epidemiological issues (32.7–40.1 % of abstracts), prevention (5.8–15.3 %), and research (8.3–10.6 %). Clinical papers made up from 2.8 % to 8.2 % of the studies published. They concluded that English-language suicide journals publish a preponderance of epidemiological studies, and that clinical studies are relatively underrepresented.

Hjelmeland (2016) scrutinized the type of studies and findings of all publications in the same printed journals in the period 2011–2012, and found that approximately 60 % of the studies in ASR and SLTB, and almost 30 % in Crisis, focused on risk factors for suicidal behaviors. The proportion of qualitative studies (or studies containing a qualitative component) was 5.6 % compared with barely 3 % in the period 2005–2008 (Hjelmeland & Knizek, 2011).

Recent Developments in Suicide Research

What has fueled the rapid increase in suicide research is the advancement, refinement, and sophistication of statistical methods; surveillance techniques and approaches; biological and genetic research; and research methodologies for the study of low-base rate behaviors at the individual and population level. As each research area makes dramatic strides, there have been pendulum swings in the foci and thrust of suicide research. Such pendulum swings are reflected in the ever-expanding long lists of risk factors and protective factors associated with suicide and suicide-related behaviors. Franklin et al. (2017) called for a paradigm shift in how we study suicide and suicide-related behaviors. One of the key messages for future research from Glenn and colleagues’ recent meta-analysis is that we need to move beyond the usual suspects of suicide risk factors (e.g., mental disorders and sociodemographic factors) to understand the processes that combine to lead to this deadly outcome (Glenn et al., 2018).

|12|The use of new technologies (including social media and naturalistic real-time monitoring via smartphones) to increase understanding of suicidal behavior and to better identify suicide risk is an exciting development. With the proliferation of smartphone ownership globally, in low- and middle-income countries (James, 2014) as well as in high-income countries, there has been much interest in using it as a tool for real-time monitoring and intervention (de Beurs et al., 2015; Chapter 16 in the present work). Given the field’s continued inability to predict suicidal behavior with sufficient sensitivity and specificity (de Beurs et al., 2015; Franklin et al., 2017; O’Connor & Nock, 2014), the use of smartphone technologies affords the opportunity to assess risk factors repeatedly, in real time and in naturalistic settings (de Beurs et al., 2015; Michaels et al., 2015).

It is hoped that the use of such technologies will better capture the waxing and waning nature of suicidal ideation (Joiner & Rudd, 2000; Zisook et al., 2009) and account for the complex interaction between the risk factors which predict the transition to suicide attempts (de Beurs et al., 2015; O’Connor & Kirtley, 2018). If the promise of new technologies is realized, individuals or clinicians may be able to better identify windows of acute risk in real time (based, in part, on social media and moment-to-moment monitoring), alert others, and hopefully complete interventions to alleviate that risk. Needless to say, there are many practical and ethical barriers that have yet to be overcome, but they are not insurmountable.

The use of ecological momentary assessment (via mobile phones) has already been shown to be feasible (Husky et al., 2014; Palmier-Claus et al., 2011), and it offers considerable promise in enhancing our prediction of the suicidal ideation–suicide attempts gap (Myin-Germeys et al., 2009). Also in Asia, text mining and machine learning approaches have been applied to Chinese social media to identify language markers of suicide risk and emotional distress (Cheng et al., 2017). Social media are also being used frequently by young people as a means of communicating distress (Marchant et al., 2017). Although these developments are exciting, best practice guidelines need to be developed to ensure these technologies are implemented safely and ethically (Michaels et al., 2015).

The use of innovative study designs and new techniques are important developments. The statistical and computing power of big data and machine learning is now being applied to suicide risk assessment. Such approaches have the advantage of being able to combine large numbers of risk factors in the prediction of suicide risk, and they have already been shown to be moderately successful (Franklin et al., 2017; Hettige et al., 2017; Kessler et al., 2017). Another technique is the retrospective timeline follow-back (TLFB) methodology (Sobell & Sobell, 1992) which systematically assesses behaviors and events in the days and weeks preceding an index event. Its application within a case-crossover design to understand suicide risk in the days and hours preceding a suicide attempt is novel. Implicit cognitions toward death assess one’s automatic associations with life or death, and may serve to predict suicidal behavior (Nock et al., 2010). Finally, network analysis is a new statistical technique that has been applied to psychopathology in general and suicidal behavior specifically in recent years (de Beurs, 2017; de Beurs et al., 2017; Fried et al., 2017). Network analysis allows the investigation of complex associations between risk factors or symptoms. It also determines which symptoms are central within a network, thereby highlighting specific treatment targets with the potential to be most powerful in reducing risk of suicidal behavior.

As noted above, a recent meta-analytic review of longitudinal studies assessing suicidal thoughts and behaviors (Franklin et al., 2017) concluded that traditional statistical approaches may not be ideal in accurately predicting the occurrence of suicidal behaviors. Rather, several studies have applied machine learning techniques to electronic health records within large medical databases. For instance, Walsh, Ribeiro, and Franklin (2017) found that |13|machine learning algorithms, applied to a large sample of adult patients with a claim code for self-injury, were relatively accurate (i.e., area under the curve = 0.84) predictors of future suicide attempts.

Another new development has been the recognition of the importance of postvention and involvement of those with lived experience (including suicide attempt survivors and suicide bereavement survivors) as key to suicide research and prevention activities (O’Connor & Portzky, 2018b). Lezine (2016) recently described the vital work of suicide prevention through personal experience. Involving those with lived experience in conducting suicide research allows the person with lived experience (peer specialist) to provide crucial insights into how to have conversations around suicide and how best to ask the questions about thoughts of suicide directly (Huisman & van Bergen, 2019).

Conclusions

Although the recent epidemiological data suggest that we have made very little headway in significantly reducing the overall worldwide suicide rate in the last 50 years, the research findings have been accumulating. The building blocks have been put in place: The critical factors have been identified and methodologies to study the problems have been evolving (Silverman et al., 2014).

We are on the brink of new breakthroughs in many areas and lines of research. As suicide prevention research has advanced to address risk detection, clinical course, treatment development, comparative effectiveness, implementation, evaluation, and follow-up parameters, the contexts for research have also become more diverse. There is continual reinforcement and innovative engagement across many lines of inquiry. Progress will require interdisciplinary, collaborative science; likewise, coordinated, collaborative approaches to supporting research, involving both public and private partners, can effectively advance the prevention of suicide through cross-cutting and interactive research (Silverman et al., 2014).

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