Social Science and Medicine, 72(4), February 2011, pp.608-616.
Publisher:
Elsevier
Fourteen case-control and cohort studies were included in this systematic review and meta-analysis. Although relative risk for suicide was much higher for psychiatric disorders compared to socioeconomic factors, the population attributable risk for some socioeconomic factors and some psychiatric disorders were found to be of the same order of magnitude. The suggestion that public health policy on suicide prevention should focus on lower risk, but higher prevalence, socioeconomic factors is discussed.
Fourteen case-control and cohort studies were included in this systematic review and meta-analysis. Although relative risk for suicide was much higher for psychiatric disorders compared to socioeconomic factors, the population attributable risk for some socioeconomic factors and some psychiatric disorders were found to be of the same order of magnitude. The suggestion that public health policy on suicide prevention should focus on lower risk, but higher prevalence, socioeconomic factors is discussed.
Extended abstract:
Author
Li Zhuoyang; et al.
Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: a systematic review.
Journal citation/publication details
Social Science and Medicine, 72(4), February 2011, pp.608-616.
Summary
Fourteen case-control and cohort studies were included in this systematic review and meta-analysis. Although relative risk for suicide was much higher for psychiatric disorders compared to socioeconomic factors, the population attributable risk for some socioeconomic factors and some psychiatric disorders were found to be of the same order of magnitude. The suggestion that public health policy on suicide prevention should focus on lower risk, but higher prevalence, socioeconomic factors is discussed.
Context
Suicide has been associated with a range of risk factors both distal and proximal. The two most commonly studied risk factors are mental disorders and socioeconomic status, SES. The aim of this study was to systematically review ‘the risk of suicide with high prevalence [psychiatric] disorders and key SES measures in population-based studies of suicide’ and ‘estimate the [associated] population attributable risk of suicide’.
Methods
What sources were searched? The online databases Medline and EMBASE were searched from 1966 and 1980, respectively, to December 2009. The reference lists of relevant articles and previous reviews were hand searched for additional studies.
What search terms/strategies were used? Searches were carried out using the keywords ‘suicide’ and (‘affective disorder’ or ‘anxiety disorder’ or ‘psychosis’ or ‘personality disorder’ or ‘substance abuse’) and (’socio-economic factors’) and (‘case-control studies’ or ‘cohort studies’).
What criteria were used to decide on which studies to include? Studies had to be case control or cohort studies with suicide as the main outcome and in which relative risk of suicide was reported, or could be estimated, for either mental disorder or an individual level SES measure. Population-based controls in case-control studies were allowed. Separate gender estimates were required and cohort studies had to include a minimum follow-up period of one year. Psychiatric disorders, based on an ICD or DSM definition, could come from a self-reported or clinical diagnosis.
Who decided on their relevance and quality? Study selection was based firstly on titles only, and then on abstracts. The selection process is outlined in Figure 1 and includes reasons for exclusion. There is no indication of who was responsible for study selection. Study quality was not formally assessed.
How many studies were included and where were they from? The database searches yielded 2,142 references, 691 of which were deemed potentially relevant. A total of 478 papers were rejected based on their abstracts, leaving 213 studies for further evaluation. Fourteen articles were finally included in the systematic review and meta-analysis. Study settings included North America, Scandinavia, and North Asia.
How were the study findings combined? Data was extracted and coded. Studies were grouped according to five psychiatric disorder categories and four socio-economic factor categories. Studies were also grouped according to whether the risk estimates were reported for males, females, or as a total for those where analyses were not stratified by gender. Meta-analysis was carried out using Stata Version 10.1. Relative risk, RR, and population attributable risk, PAR, associated with suicide were estimated for psychiatric disorders and socio-economic status. RR estimates were stratified by age group, geographic region and study design. Further details of statistical methods are available in the text.
Findings of the review
The magnitude of risk for suicide was four to five times higher for psychiatric disorders compared to socioeconomic factors. The relative risk of suicide associated with any mental disorder was 7.49 (95% CI 6.21 to 9.05) in males and 11.94 (95% CI 9.87 to 14.44) in females. For socioeconomic factors the overall relative risk of suicide for those in the lowest socioeconomic group compared to the highest group was 2.06 (95% CI 1.51 to 2.82) for males and 1.51 (95% CI 1.22 to 1.88) for females.
Population attributable risk was of a similar magnitude for some psychiatric disorders and socioeconomic factors. In males median PAR for low educational achievement was 40.9% (range 18.5% to 46.5%) and low occupational status was 33.1% (20.5% to 43.7%) while PAR for affective disorder was 26.3% (range 6.7% to 45.4%) and substance use disorders was 9.0% (range 5.0% to 23.9%). In females the PAR for low educational achievement was 20.3% (range 18.7% to 21.8%) compared to a similar magnitude for affective disorders (31.6%, range 18.6% to 66.8%), substance use disorders (25.4% range 4.8% to 31.9%) and anxiety disorders (11.7%, range 5.5% to 21.6%).
A number of gender differences were reported: there was a higher relative risk in males than females for personality disorders and the socioeconomic factors of education and occupation, and a higher relative risk for females than males for substance use disorders and anxiety disorders.
Authors' conclusions
Both psychiatric factors and socio-economic factors are associated with increased risk of suicide in populations. The population attributable risk estimates for suicide were similar in magnitude for socio-economic factors and some psychiatric factors. ‘Interventions relating to prevention of suicide should focus not only on individual psychiatric factors (high risk, low prevalence) but also the potential effects of interventions relating to broader socio-economic factors (low risk, high prevalence).’
Implications for policy or practice
None are discussed.
Subject terms:
mental health problems, risk, socioeconomic groups, suicide;
This report explores the links between socioeconomic disadvantage and suicidal behaviour, setting out how low income and unmanageable debt, unemployment, poor housing, and other socioeconomic factors contribute to high suicide rates in the most disadvantaged communities. The report finds that suicide risk increases during periods of economic recession while countries with higher levels of per capita spending on active labour market programmes, and which have more generous unemployment benefits, experience lower recession-related rises in suicides. There is a strong association between area-level deprivation and suicidal behaviour: suicide rates are two to three times higher in the most deprived neighbourhoods compared to the most affluent. The risk of suicidal behaviour increases when an individual faces negative life events, such as adversity, relationship breakdown, social isolation, or experiences stigma, emotional distress or poor mental health. Socioeconomically disadvantaged individuals are more likely to experience ongoing stress and negative life events, thus increasing their risk of suicidal behaviour. In the UK, socioeconomically disadvantaged individuals are less likely to seek help for mental health problems than the more affluent, and are less likely to be referred to specialist mental health services following self-harm by GPs located in deprived areas. The report makes a number of recommendations for action, and calls on government, businesses, industry and sector leaders to work together so that fewer people die by suicide.
(Edited publisher abstract)
This report explores the links between socioeconomic disadvantage and suicidal behaviour, setting out how low income and unmanageable debt, unemployment, poor housing, and other socioeconomic factors contribute to high suicide rates in the most disadvantaged communities. The report finds that suicide risk increases during periods of economic recession while countries with higher levels of per capita spending on active labour market programmes, and which have more generous unemployment benefits, experience lower recession-related rises in suicides. There is a strong association between area-level deprivation and suicidal behaviour: suicide rates are two to three times higher in the most deprived neighbourhoods compared to the most affluent. The risk of suicidal behaviour increases when an individual faces negative life events, such as adversity, relationship breakdown, social isolation, or experiences stigma, emotional distress or poor mental health. Socioeconomically disadvantaged individuals are more likely to experience ongoing stress and negative life events, thus increasing their risk of suicidal behaviour. In the UK, socioeconomically disadvantaged individuals are less likely to seek help for mental health problems than the more affluent, and are less likely to be referred to specialist mental health services following self-harm by GPs located in deprived areas. The report makes a number of recommendations for action, and calls on government, businesses, industry and sector leaders to work together so that fewer people die by suicide.
(Edited publisher abstract)
Subject terms:
self-harm, suicide, mental health problems, socioeconomic groups, unemployment, poverty, social exclusion;
This report is the seventh in the series 'Indications of Public Health in the English Regions' commissioned by the Chief Medical Officer. It has been produced by the Association of Public Health Observatories, led by the North East Public Health Observatory. Mental health is identified as one of the six national priorities for action in the White Paper Choosing Health In the past, indicators of mental health have been hard to find. Targets for mental health improvement have largely concentrated on suicide rates, which although important, give a limited picture of the mental health of a community. This report presents a wide range of data on the factors which can give rise to poor mental health, the mental health status of populations, provision of interventions of care for mental illness, service user experience and traditional outcomes such as suicide. Many of the risk factors for mental illness are linked to deprivation, so a general pattern occurs with the three northern regions (North East, North West and Yorkshire and Humber), showing worse measures than the three southern regions (South East, South West and Eastern England) and the two midlands regions (West Midlands, East Midlands) in between. London has a very inconsistent pattern appearing at different places on different indicators. The service based indicators do not often show this pattern, with the northern regions often doing better.
This report is the seventh in the series 'Indications of Public Health in the English Regions' commissioned by the Chief Medical Officer. It has been produced by the Association of Public Health Observatories, led by the North East Public Health Observatory. Mental health is identified as one of the six national priorities for action in the White Paper Choosing Health In the past, indicators of mental health have been hard to find. Targets for mental health improvement have largely concentrated on suicide rates, which although important, give a limited picture of the mental health of a community. This report presents a wide range of data on the factors which can give rise to poor mental health, the mental health status of populations, provision of interventions of care for mental illness, service user experience and traditional outcomes such as suicide. Many of the risk factors for mental illness are linked to deprivation, so a general pattern occurs with the three northern regions (North East, North West and Yorkshire and Humber), showing worse measures than the three southern regions (South East, South West and Eastern England) and the two midlands regions (West Midlands, East Midlands) in between. London has a very inconsistent pattern appearing at different places on different indicators. The service based indicators do not often show this pattern, with the northern regions often doing better.
British Journal of Psychiatry, 187(1), July 2005, pp.49-52.
Publisher:
Cambridge University Press
Social factors have been shown to be predictors of suicide. It is not known whether these factors vary between countries. The aim was to present a first European overview of socio-economic inequalities in suicide mortality among men and women. The authors used a prospective follow-up of censuses matched with vital statistics in ten European populations. Directly standardised rates of suicide were computed for each country. In men, a low level of educational attainment was a risk factor for suicide in eight out of ten countries. Suicide inequalities were smaller and less consistent in women. In most countries, the greater the socio-economic disadvantage, the higher is the risk of suicide. The population of Turin evidenced no socio-economic inequalities. Socio-economic inequalities in suicide are a generalised phenomenon in western Europe, but the pattern and magnitude of these inequalities vary between countries. These inequalities call for improved access to psychiatric care for lower socio-economic groups.
Social factors have been shown to be predictors of suicide. It is not known whether these factors vary between countries. The aim was to present a first European overview of socio-economic inequalities in suicide mortality among men and women. The authors used a prospective follow-up of censuses matched with vital statistics in ten European populations. Directly standardised rates of suicide were computed for each country. In men, a low level of educational attainment was a risk factor for suicide in eight out of ten countries. Suicide inequalities were smaller and less consistent in women. In most countries, the greater the socio-economic disadvantage, the higher is the risk of suicide. The population of Turin evidenced no socio-economic inequalities. Socio-economic inequalities in suicide are a generalised phenomenon in western Europe, but the pattern and magnitude of these inequalities vary between countries. These inequalities call for improved access to psychiatric care for lower socio-economic groups.
Subject terms:
mental health problems, psychiatric care, socioeconomic groups, suicide, comparative studies, gender;
This report provides evidence of a strong link between socioeconomic disadvantage and suicidal behaviour, providing a deeper understanding of the nature of this association, how it might be explained, and a consideration of the implications for policy and practice. The report explores key issues from different disciplinary perspectives, including economics, geography, psychology, public health, social policy and sociology, focusing on: the impact of place on suicidal behaviour; socioeconomic disadvantage and suicidal behaviour during times of economic recession and recovery; social and labour market policies and suicidal behaviour; psychological factors underpinning the relationship between socioeconomic disadvantage and suicidal behaviour; a qualitative synthesis of the accounts of those who have self-harmed; and how people in the UK understand the impacts of socioeconomic disadvantage on their mental health and risk factors for suicide. The report finds that unemployment is a key risk factor for suicidal behaviour in men while the association is weaker for women; and the higher risk for men is exacerbated during a downturn or period of economic growth. Recognising the important role of labour market policies in shaping the experience and occurrence of unemployment and job insecurity, the report also examines how suicidal behaviour and related common mental disorders could be reduced through labour market policy design. The report also finds that the risk of suicidal behaviour increases when an individual faces negative life events, such as adversity, relationship breakdown, social isolation, or experiences stigma, emotional distress or poor mental health. Socioeconomically disadvantaged individuals are more likely to experience ongoing stress and negative life events, thus increasing their risk of suicidal behaviour. In addition, the report explores how people understand the impacts of socioeconomic disadvantage on their mental health and risk factors for suicide. The report makes a number of recommendations for action, and calls on government, businesses, industry and sector leaders to work together so that fewer people die by suicide.
(Edited publisher abstract)
This report provides evidence of a strong link between socioeconomic disadvantage and suicidal behaviour, providing a deeper understanding of the nature of this association, how it might be explained, and a consideration of the implications for policy and practice. The report explores key issues from different disciplinary perspectives, including economics, geography, psychology, public health, social policy and sociology, focusing on: the impact of place on suicidal behaviour; socioeconomic disadvantage and suicidal behaviour during times of economic recession and recovery; social and labour market policies and suicidal behaviour; psychological factors underpinning the relationship between socioeconomic disadvantage and suicidal behaviour; a qualitative synthesis of the accounts of those who have self-harmed; and how people in the UK understand the impacts of socioeconomic disadvantage on their mental health and risk factors for suicide. The report finds that unemployment is a key risk factor for suicidal behaviour in men while the association is weaker for women; and the higher risk for men is exacerbated during a downturn or period of economic growth. Recognising the important role of labour market policies in shaping the experience and occurrence of unemployment and job insecurity, the report also examines how suicidal behaviour and related common mental disorders could be reduced through labour market policy design. The report also finds that the risk of suicidal behaviour increases when an individual faces negative life events, such as adversity, relationship breakdown, social isolation, or experiences stigma, emotional distress or poor mental health. Socioeconomically disadvantaged individuals are more likely to experience ongoing stress and negative life events, thus increasing their risk of suicidal behaviour. In addition, the report explores how people understand the impacts of socioeconomic disadvantage on their mental health and risk factors for suicide. The report makes a number of recommendations for action, and calls on government, businesses, industry and sector leaders to work together so that fewer people die by suicide.
(Edited publisher abstract)
Subject terms:
literature reviews, poverty, socioeconomic groups, unemployment, self-harm, suicide, social exclusion, mental health problems;
This review considers the empirical relationship between socioeconomic disadvantage and suicidal behaviour, highlighting the evidence relating to the UK (as a whole or its constituent nations) and the Republic of Ireland. The weight of evidence summarised in the review points to a significant association between socioeconomic disadvantage (across a range of indicators at both individual and area levels), on the one hand, and suicidal behaviour (suicide and self-harm), on the other. In particular, the review focuses on unemployment and economic recession; occupational status, occupation and suicidal behaviour; education and housing tenure; socioeconomic characteristics of geographical areas; and the relative importance of individual- and area-level inequalities on suicide risk. The review identifies possible pathways to increased risk of suicidal behaviour. At the individual level, these include: accumulated adverse life-course experiences (e.g., health, employment, living conditions); powerlessness, stigma and disrespect; experiencing other features of social exclusion (e.g., poverty, poor educational attainment); living in socioeconomically deprived area; poor physical and mental health; unhealthy lifestyles, i.e. smoking; and social disconnectedness (e.g., loneliness, isolation, poor social support, negative relationships). At the contextual level, pathways to increased risk of suicidal behaviour include: physical (e.g., poor housing conditions); cultural (e.g., tolerant attitudes to suicide); political (e.g., adverse local public policy); economic (e.g., lack of job opportunities; social (e.g., weak social capital); history (e.g., high incidence of suicidal behaviour); infrastructure (e.g., poor quality, accessibility, acceptability of services); and health and well-being (e.g., high prevalence of poor physical and mental health).
(Edited publisher abstract)
This review considers the empirical relationship between socioeconomic disadvantage and suicidal behaviour, highlighting the evidence relating to the UK (as a whole or its constituent nations) and the Republic of Ireland. The weight of evidence summarised in the review points to a significant association between socioeconomic disadvantage (across a range of indicators at both individual and area levels), on the one hand, and suicidal behaviour (suicide and self-harm), on the other. In particular, the review focuses on unemployment and economic recession; occupational status, occupation and suicidal behaviour; education and housing tenure; socioeconomic characteristics of geographical areas; and the relative importance of individual- and area-level inequalities on suicide risk. The review identifies possible pathways to increased risk of suicidal behaviour. At the individual level, these include: accumulated adverse life-course experiences (e.g., health, employment, living conditions); powerlessness, stigma and disrespect; experiencing other features of social exclusion (e.g., poverty, poor educational attainment); living in socioeconomically deprived area; poor physical and mental health; unhealthy lifestyles, i.e. smoking; and social disconnectedness (e.g., loneliness, isolation, poor social support, negative relationships). At the contextual level, pathways to increased risk of suicidal behaviour include: physical (e.g., poor housing conditions); cultural (e.g., tolerant attitudes to suicide); political (e.g., adverse local public policy); economic (e.g., lack of job opportunities; social (e.g., weak social capital); history (e.g., high incidence of suicidal behaviour); infrastructure (e.g., poor quality, accessibility, acceptability of services); and health and well-being (e.g., high prevalence of poor physical and mental health).
(Edited publisher abstract)
Subject terms:
literature reviews, suicide, self-harm, mental health problems, poverty, unemployment, social exclusion, socioeconomic groups;
British Journal of Psychiatry, 183(8), August 2003, pp.155-160.
Publisher:
Cambridge University Press
Information on suicide by psychiatric patients from ethnic minority groups is scarce. This article aims to establish the number of patients from ethnic minorities who kill themselves; to describe their suicide methods, and their social and clinical characteristics. A national clinical survey was based on a 4-year sample of suicides in England and Wales. Detailed data were collected on those who had been in contact with mental health services in the year before death. In total 282 patients from ethnic minorities died by suicide – 6% of all patient suicides. The most common method of suicide was hanging; violent methods were more common than in White patient suicides. Schizophrenia was the most common diagnosis. Ethnic minority patients were more likely to have been unemployed than White patients and to have had a history of violence and recent non-compliance. In around half, this was the first episode of self-harm. Black Caribbean patients had the highest rates of schizophrenia (74%), unemployment, living alone, previous violence and drug misuse. In order to reduce the number of suicides by ethnic minority patients, services should address the complex health and social needs of people with severe mental illness.
Information on suicide by psychiatric patients from ethnic minority groups is scarce. This article aims to establish the number of patients from ethnic minorities who kill themselves; to describe their suicide methods, and their social and clinical characteristics. A national clinical survey was based on a 4-year sample of suicides in England and Wales. Detailed data were collected on those who had been in contact with mental health services in the year before death. In total 282 patients from ethnic minorities died by suicide – 6% of all patient suicides. The most common method of suicide was hanging; violent methods were more common than in White patient suicides. Schizophrenia was the most common diagnosis. Ethnic minority patients were more likely to have been unemployed than White patients and to have had a history of violence and recent non-compliance. In around half, this was the first episode of self-harm. Black Caribbean patients had the highest rates of schizophrenia (74%), unemployment, living alone, previous violence and drug misuse. In order to reduce the number of suicides by ethnic minority patients, services should address the complex health and social needs of people with severe mental illness.
Subject terms:
social isolation, mental health problems, patients, psychiatry, risk, self-harm, schizophrenia, socioeconomic groups, suicide, surveys, unemployment, black and minority ethnic people, depression, ethnicity;
British Journal of Psychiatry, 183(8), August 2003, pp.100-101.
Publisher:
Cambridge University Press
Suicide rates are higher in areas where ethnic minority groups are in lower concentration. This is not due to confounding by gender, age, deprivation or unbalanced migration. This effect may not be due to ethnicity per se, as other density effects have been demonstrated. At an individual level, socio-economic stress, thwarted aspirations, racism, acculturation, culture clash with parents, loss of religious affiliation, difficulty with identity formation, and loss of family and community support may have effects on suicide risk. However, context is important; all of these risk factors are influenced by the socio-economic situation of the group, its culture and history, and the mainstream social environment.
Suicide rates are higher in areas where ethnic minority groups are in lower concentration. This is not due to confounding by gender, age, deprivation or unbalanced migration. This effect may not be due to ethnicity per se, as other density effects have been demonstrated. At an individual level, socio-economic stress, thwarted aspirations, racism, acculturation, culture clash with parents, loss of religious affiliation, difficulty with identity formation, and loss of family and community support may have effects on suicide risk. However, context is important; all of these risk factors are influenced by the socio-economic situation of the group, its culture and history, and the mainstream social environment.
Subject terms:
social isolation, mental health problems, prevention, psychiatry, risk, socioeconomic groups, suicide, black and minority ethnic people, cultural identity, depression, ethnicity;
This report presents the findings from a survey of psychiatric morbidity among adults aged 16 to 74 living in private households in Great Britain. The report focuses mainly on the extent to which people with different types of mental disorder (neuroses, psychoses, alcohol and drug dependence) differ from those without a disorder on: educational attainment, economic activity, financial circumstances, housing, activities of daily living, the experience of stressful events and social functioning.
This report presents the findings from a survey of psychiatric morbidity among adults aged 16 to 74 living in private households in Great Britain. The report focuses mainly on the extent to which people with different types of mental disorder (neuroses, psychoses, alcohol and drug dependence) differ from those without a disorder on: educational attainment, economic activity, financial circumstances, housing, activities of daily living, the experience of stressful events and social functioning.
Subject terms:
mental health problems, severe mental health problems, social exclusion, socioeconomic groups, stress, substance misuse, suicide, statistical methods, activities of daily living, demographics, educational performance;