the social construction and subjective meaning of attempted suicide_sisask_dok

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TALLINNA ÜLIKOOL SOTSIAALTEADUSTE DISSERTATSIOONID

TALLINN UNIVERSITY

DISSERTATIONS ON SOCIAL SCIENCES

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Merike Sisask

The social construction and subjective meaning of attempted suicide

TALLINN 2010

TALLINNA ÜLIKOOL SOTSIAALTEADUSTE DISSERTATSIOONID TALLINN UNIVERSITY DISSERTATIONS ON SOCIAL SCIENCES 47 Merike Sisask THE SOCIAL CONSTRUCTION AND SUBJECTIVE MEANING OF ATTEMPTED SUICIDE Institute of International and Social Studies, Tallinn University, Tallinn, Estonia The dissertation is accepted for the commencement of the degree of Doctor Philosophiae in Sociology by the Doctoral Committee of Social Sciences of the Tallinn University on November 17, 2011. Supervisors Airi Värnik, MD PhD, Professor at the Institute of Social Work of Tallinn

University; Director of the Estonian-Swedish Mental Health and Suicidology Institute (ERSI) Mikko Kari Lagerspetz, Dr. rer. pol, Professor at the Department of Sociology of Åbo Akademi University

Opponents Ilkka Henrik Mäkinen, PhD, LL.M, Professor at the Stockholm Centre on

Health of Societies in Transition (SCOHOST) of the School of Social Sciences of Södertörn University

Jaanus Harro, MD PhD, Professor at the Chair of Psychophysiology of the Institute of Psychology of the Faculty of Social Sciences and Education of the University of Tartu

The academic disputation on the dissertation will be held on January 14, 2011 at 10 o’clock, at Tallinn University lecture hall M-213, Uus-Sadama 5, Tallinn. Copyright: Merike Sisask, 2010 Copyright (abstract, online, PDF): Tallinna Ülikool, 2010 ISSN 1736-3632 (printed publication) ISBN 978-9949-463-61-9 (printed publication) ISSN 1736-793X (online, PDF) ISBN 978-9949-463-62-6 (online, PDF) ISSN 1736-3675 (abstract, online, PDF) ISBN 978-9949-463-63-3 (abstract, online, PDF) Tallinn University Narva mnt 25 10120 Tallinn www.tlu.ee

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CONTENTS ABSTRACT ............................................................................................................................ 7 LIST OF PUBLICATIONS ..................................................................................................... 9 ACKNOWLEDGEMENTS .................................................................................................. 12 PREFACE ............................................................................................................................. 14 THEORETICAL FRAMEWORK ......................................................................................... 15

General theoretical underpinnings .................................................................................... 15 Attempted suicide ............................................................................................................. 18 Suicidal intent ................................................................................................................... 21 Well-being ........................................................................................................................ 21 Religiosity ......................................................................................................................... 23

RESEARCH PROBLEM AND AIMS .................................................................................. 25 RESEARCH DESIGN, METHODS AND DATA ................................................................ 27

Overall research design and participating sites ................................................................. 27 Emergency-care departments and settings for the community survey .............................. 28 Subjects and data collection procedure ............................................................................. 28 Instruments ....................................................................................................................... 30 Data analysis ..................................................................................................................... 31

RESULTS AND DISCUSSION ............................................................................................ 33 Qualitative sociocultural description of participating sites ............................................... 33

Campinas (Brazil) ........................................................................................................ 33 Tallinn (Estonia)........................................................................................................... 34 Chennai (India)............................................................................................................. 35 Karaj (The Islamic Republic of Iran) ........................................................................... 36 Colombo (Sri Lanka) .................................................................................................... 36 Hanoi (Vietnam)........................................................................................................... 38

Characteristics of suicide attempters................................................................................. 39 Enrolment of suicide attempters ................................................................................... 39 Sociodemographic characteristics ................................................................................ 39 Main method of attempted suicide ............................................................................... 40 Consequences of attempted suicide and aftercare ........................................................ 41

Religiosity and attempted suicide ..................................................................................... 41 Religious denomination................................................................................................ 42 Organisational religiosity ............................................................................................. 43 Subjective religiosity .................................................................................................... 44

Assessment of the severity of attempted suicide ............................................................... 44 Factorial structure of the Pierce Suicidal Intent Scale (PSIS) ...................................... 45 Gender differences in suicidal intent ............................................................................ 45 Age differences in suicidal intent ................................................................................. 46 Self-rated suicidal intent with respect to external characteristics ................................. 47 Associations with well-being, depression and hopelessness ........................................ 48

CONCLUSIONS ................................................................................................................... 50

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KOKKUVÕTE ...................................................................................................................... 52 REFERENCES ...................................................................................................................... 55 APPENDIXES ...................................................................................................................... 99 ELULOOKIRJELDUS ........................................................................................................ 163 PUBLIKATSIOONID ......................................................................................................... 164 CURRICULUM VITAE ..................................................................................................... 170 PUBLICATIONS ................................................................................................................ 171

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ABSTRACT

The most important tradition in the study of suicide within sociology was initiated by Émile Durkheim (1897/2002). According to Durkheim, suicide is a collective social phenomenon: a social fact. The current dissertation is written within a theo-retical framework which applies concepts such as post-material values, culture and subjective well-being (Inglehart 1997); active self (Giddens 1991/2004); subjective meaning of behaviours (Weber et al. 1921/1978; Douglas 1967); and the construc-tion of reality in everyday life through interaction (Berger and Luckmann 1966/1991; Spector and Kitsuse 1987; Searle 1995). A common feature of these theories is the phenomenological approach which puts individuals as active agents in the centre of social reality, claims that social reality is created through interac-tion, and prioritises the subjective meaning individuals attach to their behaviour.

The aim of the current dissertation is to analyse attempted suicide as a social phe-nomenon, thereby giving sense to the formal social structure, social construction and subjective meaning of the phenomenon. The empirical material was collected within the framework of the WHO SUPRE-MISS study, the aim of which was to increase knowledge about suicidal behaviours in culturally diverse places around the world. Participating sites were selected from low- and middle-income countries, where less research was available about attempted suicide: Campinas (Brazil), Chennai (India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Vietnam), Karaj (the Islamic Republic of Iran), Tallinn (Estonia) and Yuncheng (People’s Republic of China). Data collection was performed from 2002 to 2004. Structured face-to-face interviews were conducted with medically-treated suicide attempters (n = 4,314) and with a control group (n = 5,484). Qualitative site descriptions about the sociocultural background of suicidal behaviours were compiled.

The current dissertation is based on four articles all dealing with the same empirical material and the subject of attempted suicide but each from a slightly different per-spective. The theoretical framework incorporates the articles under a single socio-logical umbrella and builds bridges between them. The first article shows how sui-cide attempters were identified in everyday interaction at emergency care depart-ments of general hospitals and highlights the fact that accurate, standardised infor-mation on the rates and characteristics of medically-treated suicide attempters is essential for the development and evaluation of preventive services. Problems with data collection vary across the countries included in this study, largely due to cul-tural and socioeconomic factors. The second article reveals that individual-level associations between the different dimensions of religiosity and suicide attempting exist. These associations vary between dimensions of religiosity and across cul-tures. In particular, subjective religiosity may serve as a protective factor against non-fatal suicidal behaviours in some cultures. Structural and formal religious di-mensions (religious denomination, organisational religiosity) seem to be less rele-vant. The third and the fourth articles are based on the Estonian data only and are concerned with the subjective meaning the respondents give to their suicidal acts.

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These articles show how the severity of attempted suicide can be assessed by meas-uring the level of suicidal intent and by correlating the suicidal intent scale with self-rated measures of emotional status. The level of suicidal intent gives valuable information regarding the suicidal person’s true intention in addition to objective, external observations. Subjective psychological well-being as an emotional status is highly relevant in the assessment of the severity of attempted suicide.

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LIST OF PUBLICATIONS

The following original publications are included in the current dissertation and will be re-ferred to in the text of the dissertation by their respective number (in Roman numerals).

I. Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Botega, N., Phillips, M., Sisask, M., Vjayakumar, L., Malakouti, K., Schlebusch, L., De Silva, D., Nguyen, V. T. and Wasserman D. (2005). Characteristics of attempted suicides seen in emer-gency-care settings of general hospitals in eight low- and middle-income countries. Psychological Medicine, 35(10): 1467-1474.

II. Sisask, M., Värnik, A., Kõlves, K., Konstabel, K. and Wasserman, D. (2008). Subjec-tive psychological well-being (WHO-5) in assessment of the severity of suicide at-tempt. Nordic Journal of Psychiatry, 62(6): 431-435.

III. Sisask, M., Värnik, A. and Kõlves, K. (2009). Severity of attempted suicide as meas-ured by the Pierce Suicidal Intent Scale. Crisis, 30(3): 136-143.

IV. Sisask, M., Värnik, A., Kõlves, K., Bertolote, J. M., Bolhari, J., Botega, N. J., Fleisch-mann, A., Vijayakumar, L. and Wasserman D. (2010). Is Religiosity a Protective Fac-tor Against Attempted Suicide: A Cross-Cultural Case-Control Study. Archives of Sui-cide Research, 14(1): 44-55.

The author of the dissertation has contributed to these four publications as follows: (1) Article I: carrying out and organising data collection, participating in writing the manu-

script, giving final approval to the manuscript; (2) Articles II, III and IV: formulating the research question, creating research design,

carrying out and organising data collection, checking and validating data, carrying out data analysis and interpretation, writing manuscripts, giving final approval to the manu-scripts.

Additional articles of direct relevance Bertolote, J. M., Fleischmann, A., De Leo, D., Phillips, M. R., Botega, N. J., Vjayakumar, L., De Silva, D., Schlebusch, L., Nguyen, V. T., Sisask, M., Bolhari, J. and Wasserman, D. (2010). Repetition of suicide attempts: data from five culturally different low- and middle-income country emergency care settings participating in the WHO SUPRE-MISS study. Crisis, 31(4): 194-201.

Sisask, M., Värnik, A. and Wasserman, D. (2005). Internet Comments on Media Reporting of Two Adolescents’ Collective Suicide Attempt. Archives of Suicide Research, 1: 87-98.

Sisask, M., Kõlves, K. and Värnik, A. (2004). Suitsidaalsus ühiskonnas ja suitsiidikatse sooritamist prognoosivad tegurid. [Suicidality in society and the factors predicting suicide attempt.] Eesti Arst, 83: 744-749.

Sisask, M., Kõlves, K., Värnik, A. and Wasserman, D. (2003). WHO-SUPRE – Üle-maailmne suitsiidikatsete uuring Eestis. [WHO-SUPRE – Worldwide suicide attempts study in Estonia.] Suitsiidiuuringud – Suicide Studies. ERSI 10. aastapäeva kogumik. ERSI 10th anniversary collected papers. A. Värnik (Ed.). Tallinn: Iloprint: 65-69.

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Kõlves, K. and Sisask, M. (2003). WHO SUPRE-MISS uuringu kontrollgrupp – suitsidaal-sus populatsioonis ja probleemid ühiskonnas. [WHO SUPRE-MISS control group study – suicidality in the population and problems in the society.] Suitsiidiuuringud – Suicide Stud-ies. ERSI 10. aastapäeva kogumik. ERSI 10th anniversary collected papers. A. Värnik (Ed.). Tallinn: Iloprint: 70-73.

Tihaste, M., Sisask, M. and Värnik, A. (2003). WHO SUPRE-MISS: suitsiidikatse soorita-nute rehabilitatsioon. [WHO SUPRE-MISS: rehabilitation of suicide attempters.] Suit-siidiuuringud – Suicide Studies. ERSI 10. aastapäeva kogumik. ERSI 10th anniversary col-lected papers. A. Värnik (Ed.). Tallinn: Iloprint: 87-90.

Conference papers of direct importance Sisask, M., Värnik, A. and Wasserman, D. (2002). Suicidal behaviour among young people in Estonia: A case analysis. 9th ESSSB, Warwick, England: PO22.

Sisask, M., Kõlves, K., Värnik, A. and Wasserman, D. (2003). SUPRE-MISS in Estonia – main risk groups among suicide attempters. XXII World Congress of IASP, Stockholm, Sweden: 102:3.

Tihaste, M., Sisask, M., Värnik, A. and Wasserman, D. (2003). WHO SUPRE-MISS: Reha-bilitation for suicide attempters. XXII World Congress of IASP, Stockholm, Sweden: 110:1.

Sisask, M., Kõlves, K. and Värnik, A. (2003). WHO-SUPRE: Ülemaailmne suitsiidikatsete uuring Eestis [WHO SUPRE-MISS: Worldwide study of suicide attempts in Estonia]. II Annual Conference of Estonian Centre for Behavioural and Health Sciences, Pühajärve, Estonia.

Sisask, M and Värnik, A. (2004). Suitsiidikatse kajastamine meedias ja sellelejärgnenud Interneti kommentaarid [Media portrayal of a suicide attempt and following comments in the Internet]. III Annual Conference of Estonian Centre for Behavioural and Health Sciences, Võru-Kubija, Estonia.

Sisask, M. and Värnik, A. (2004). Kahe teismelise ühise suitsiidikatse kajastamine meedias ja sellele järgnenud Interneti kommentaarid [Media portrayal of a teenagers’ simultaneous suicide attempt and following comments in the Internet]. V Annual Conference of Estonian Social Sciences, Tartu, Estonia.

Sisask, M. and Värnik, A. (2005). WHO SUPRE-MISS: Suitsiidikatse sooritanute psüühiline terviseseisund ja kontakt tervishoiuasutustega [Psychic health status and contact with health care services among suicide attempters]. IV Annual Conference of Estonian Centre for Be-havioural and Health Sciences, Pärnu, Estonia.

Sisask, M., Kõlves, K., Samm, A., Anion, L., Raudsepp, J. and Värnik, A. (2006). Suitsiidi-katse raskusastme määratlus ja selle seos psüühilise seisundiga [Assessment of the severity of suicide attempt and association with psychic status]. V Annual Conference of Estonian Centre for Behavioural and Health Sciences, Roosta, Estonia.

Raudsepp, J., Sisask, M., Värnik, A., De Leo, D., Wasserman, D., Fleischmann, A., Botega, N., Phillips, M., Vijayakumar, L., Bolhari, J., Schlebusch, L., De Silva, D., Nguyen, V. T. and Berolote, J. M. (2007). Does religion pretect against suicide attempt: WHO SUPRE-MISS study. XXIV World Congress of IASP, Killarney, Ireland: OR022.

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Sisask, M., Värnik, A., Kõlves, K., Wasserman, D., De Leo, D., Berolote, J. M., Botega, N., Phillips, M., Vijayakumar, L., Bolhari, J., Schlebusch, L., De Silva, D., Nguyen, V. T. and Fleischmann, A. (2007). Subjective psychological well-being WHO-5 in assessment of the severity of suicide attempt: WHO SUPRE-MISS study. XXIV World Congress of IASP, Killarney, Ireland: OR069.

Sisask, M., Värnik, A., Kõlves, K., Wasserman, D., De Leo, D., Berolote, J. M., Botega, N., Phillips, M., Vijayakumar, L., Bolhari, J., Schlebusch, L., De Silva, D., Nguyen, V. T. and Fleischmann, A. (2007). Subjektiivne psühholoogiline heaolu suitsiidikatse raskusastme määratlemisel [Subjective psychological well-being in assessment of the severity of suicide attempt]. VI Annual Conference of Estonian Centre for Behavioural and Health Sciences, Toila, Estonia.

Sisask, M and Värnik, A. (2008). Brief intervention after attempted suicide: findings from WHO SUPRE-MISS in Estonia. 9th World Conference on Injury Prevention and Safety Promotion, Merida, Mexico.

Sisask, M., Värnik, A., Kõlves, K., Bertolote, J. M., Bolhari, J., Botega, N. J., Fleischmann, A., Vijayakumar, L. and Wasserman, D. (2008). Religioossus kui kaitsetegur suitsiidikatse vastu: WHO SUPRE-MISS juhtkontroll uuring [Religiosity as a protective factor against attempted suicide: WHO SUPRE-MISS case-control study]. VII Annual Conference of Estonian Centre for Behavioural and Health Sciences, Narva-Jõesuu, Estonia.

Sisask, M., Värnik, A., Kõlves, K., Konstabel, K. and Wasserman, D. (2009). Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. 29th Nordic Congress of Psychiatry (Session: Best research from all countries published in Nor-dic Journal of Psychiatry in 2006-2008), Stockholm, Sweden.

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ACKNOWLEDGEMENTS

In my professional career as a social scientist, I have learned and achieved more than I could have hoped for and there are many people I am deeply grateful to for having helped me realise my dreams.

This dissertation has been written under the supervision of Prof. Dr. Airi Värnik and Prof. Mikko Kari Lagerspetz. Airi has been my teacher, my mentor and one of my best friends for a decade now and is the person who has ‘infected’ me with a love for academic studies. To Airi I owe everything I am in suicidology. Furthermore, her day-to-day company has helped me develop as a person. Mikko has opened my eyes to the world of sociology and I owe him thanks for his support and suggestions and because of him I dare to identify myself as a sociologist.

The empirical material for my dissertation was collected within the framework of the WHO SUPRE-MISS study, which was the first project I was involved in after joining the Estonian-Swedish Mental Health and Suicidology Institute (ERSI) re-search group, established and led by Airi. I am most thankful to all my colleagues from the SUPRE-MISS consortium for the possibility to experience such a high level of international collaboration already at the very beginning of my academic career. Many of the co-authors of the articles I have published – such as Prof. Dr. Danuta Wasserman, Kairi Kõlves and Alexandra Fleischmann – are much more than just colleagues to me. I highly appreciate the fieldwork carried out by the in-terviewers and the implementation of the SUPRE-MISS project would not have been possible without the financial support given by WHO, the Estonian Health Insurance Foundation and the Estonian Centre of Behavioural and Health Sciences.

I am grateful to my colleagues from ERSI for their helpfulness and encouragement in finalising my dissertation in time. Special thanks go to Kairi Kõlves, a dear friend who has not only helped in data processing, but also in continuous methodo-logical consultation, and the always optimistic and supportive Mare Raidla.

I would like to express my gratitude to the Institute of International and Social Studies, which has kindly hosted me during my PhD studies at Tallinn University. I have also been able to experience the working style of other international research groups by way of cooperation with the National Prevention of Suicide and Mental Ill-Health (NASP) at the Karolinska Institute in Stockholm (thanks to Prof. Dr. Danuta Wasserman) and the Research Unit in Health, Behaviour and Change (RUHBC) at the University of Edinburgh (thanks to Prof. Stephen Platt). During my PhD studies, four different doctoral schools at Tallinn University and the Uni-versity of Tartu – the Doctoral School of Behavioural and Health Sciences, the Doctoral School of Social Sciences, the Doctoral School of Educational Sciences, and the Doctoral School of Behavioural, Social and Health Sciences – have sup-ported my research mobility and enabled me to enrich the content of my PhD thesis.

I am also grateful to my external reviewers, Prof. Ilkka Henrik Mäkinen and Assoc. Prof. Liina-Mai Tooding, whose questions, comments and suggestions helped im-

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prove the final version of the dissertation substantially. Thanks also are due to De-laney Skerrett for his thorough linguistic revision of the dissertation.

Last but not least, my utmost gratitude goes to my immediate family – Toomas, Ats, Mats and Liisa-Lii Tamme – and my parents – Roland and Milvi Sisask – who have supported my aspirations and my commitment to this work.

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PREFACE

According to the World Health Organization (WHO), suicide is a global public health problem with an estimated global rate of suicide of 14.0 per 100 000 inhabi-tants (Bertolote 2001; 2009). Suicide rates vary widely by continent, culture and country. The latest available 5-year (2004-2008) average suicide rate in Estonia is 18.2 with the respective figure in the European Union being 10.5 (WHO/Euro MDB 2010). As Estonia is among those countries that have an elevated risk of sui-cide, continuous research on explaining suicidal behaviours is needed in order to provide evidence-based suicide prevention.

Suicidology is an interdisciplinary research area. The field of suicidology comprises issues related to sociocultural and structural contexts as well as the functions of the central nervous system at the molecular biological level (Wasserman and Wasserman 2009). The research tradition on suicide in Estonia at an internationally significant level was begun by the Wasserman and Värnik research group approxi-mately two decades ago. During this time period, suicide rates in Estonia have shown sharp fluctuations, which coincided with the turbulent socio-political and economic changes after dissolution of the USSR in 1991. In the last 15 years, the suicide rate in Estonia has decreased dramatically from 41.7 in 1994 to 16.5 in 2008. The Wasserman and Värnik research group has substantially contributed to the evidence supporting a sociological approach to suicide (Wasserman and Värnik 1994; Wasserman et al. 1997; Wasserman et al. 1998; Värnik 1998; Värnik et al. 1998; Värnik et al. 2000; Wasserman and Värnik 2001; Värnik et al. 2003; Tooding et al. 2004; Värnik 2005; Värnik and Mokhovikov 2009; Värnik and Wasserman 2009; Värnik et al. 2010).

The spectrum of suicidal behaviours goes beyond completed suicides and includes attempted suicides and suicidal ideation (plans, thoughts) as well (Wasserman 2001b; Bertolote et al. 2005; Bertolote et al. 2009). The further from completed suicide we go on this spectrum , the more problematic the comparison of studies between and among different research groups, countries and populations surveyed becomes, due to methodological discrepancies and sociocultural considerations (Silverman 2006b; Bertolote and Wasserman 2009; Mittendorfer Rutz and Schmid-tke 2009). However, there are indications that, across different sites worldwide, attempted suicides can be 10-40 times more frequent than completed suicides (Platt et al. 1992; Schmidtke et al. 1996; Bertolote 2001). The prevalence of suicidal idea-tion has been found to vary in different sites from 3% to 25% of the total population (Bertolote et al. 2005; Nock et al. 2008).

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THEORETICAL FRAMEWORK

GENERAL THEORETICAL UNDERPINNINGS

Suicidal behaviour is a complex bio-psycho-social phenomenon and scholars tend to agree that it is important to study the various aspects of the phenomenon (Wasserman and Wasserman 2009). Studies on suicidal behaviour with a sociologi-cal approach are often rooted in the classic theory of Émile Durkheim (1897/2002). According to him, the sociological method rests wholly on the basic principle that social facts must be studied as things—that is, as realities external to the individual. Suicide as a social fact cannot be explained by individual-level risk factors; it is a collective phenomenon and every society or social group has a certain inclination towards suicide during a given period of time. The fundamental issue is the level of social integration (egoistic versus altruistic suicide) and social regulation (anomic versus fatalistic suicide). Durkheim does not put emphasis on the subjective mean-ing of social facts. He says that individual events, though preceding suicides with certain regularity, are not the real causes of suicide. Absence of happiness in life does not necessarily cause people to kill themselves unless they are otherwise so inclined (270). Nevertheless, even Durkheim admits that all victims of suicide give the act a personal stamp which expresses their temperament and the special condi-tions in which they are involved. The suicide, consequently, cannot simply be ex-plained by the social and general causes of the phenomenon (241).

The majority of later sociological analysis on suicide has been in the form of criti-cism and further development of Durkheimian structural theory. For example Par-sons (1937/1968), a representative of functionalism in sociology, developed the voluntaristic theory of social actions. According to him, individuals make choices in the course of their actions, but these choices are constrained by biological and envi-ronmental conditions and by the values and norms governing the social structures in which these actions and choices occur.

The main alternative to the Durkheimian social-structural approach is based on the Weberian (1921/1978) focus on individual human actors and the constitution of social reality through subjective meanings that human actors attach to their actions. In the 20th century, more attention has been paid to the subjective meaning of sui-cidal behaviour and ethnomethodologically-inspired sociological works have even questioned the ways in which information on suicide is obtained, underlining the importance of insight into individual cases of suicide (Mäkinen 1997; 2009). Doug-las (1967) highlighted the need to cease looking at aggregate levels of suicide as social fact and rather, in order to understand the meaning of suicidal behaviours, to study real-world patterns of actions and meanings by exploring suicidal individuals’ inner world – their thoughts, beliefs, attitudes and motives. This phenomenological point of view seems to attain even more significance when attempted suicide is the research subject, as the interpretation of the suicidal phenomenon can be obtained retrospectively from the suicidal individuals themselves. But even when concentrat-ing on the subjective meanings of attempted suicides, we cannot escape the fact that

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these meanings are, in turn, influenced by the particular society’s changing value systems.

Inglehart (1997) introduced the concept of post-material values as a move toward a more humane society, with more room for individual autonomy, diversity, and self-expression (12). The postmodern trajectory shifts authority away from the aggregate level to that of the individual, and from norms to subjective meaning, with an in-creasing focus on individual concerns and individual subjective well-being. Post-material values reflect the assumption that survival can be taken for granted, which leads to a growing emphasis on the need for self-expression. Giddens (1991/2004) has stressed the interaction between the individual and institutional forces in the shaping of the structural characteristics of the world. According to him, in the con-ditions of ‘late’ or ‘high’ modernity, the self is not a passive entity determined by external influences, but rather an active agent in the construction of the reflexive project of the self. In forging their self-identities, individuals contribute to and di-rectly promote social influences that are global in their consequences and implica-tions. Thus, postmodern thinkers highlight the fact that the advance of material welfare in Western societies has produced a condition in which both the individ-ual’s well-being and the limits of his or her identity are less dependent on material and structural constraints, and more the results of his or her own agency.

At the same time, human behaviour is heavily influenced by the culture in which the individual has been socialised. By culture, Inglehart (1997) refers to the subjec-tive aspect of a society’s institutions; it is a system of attitudes, beliefs, values, knowledge and skills that is widely shared within a society, transmitted from gen-eration to generation and internalised by the people of a given society (15). How-ever, despite the high level of freedom of individual choice and the importance of subjective meanings in the contemporary world, there are certain universal features shaped by structural elements of society as noticed already by Durkheim (1897/2002) and acknowledged as well by Inglehart (1997) and Giddens (1991/2004).

Value systems are an important part of our apprehension of the world. In addition to the socialisation process and structural influences, these value systems are influ-enced by the individual’s everyday experiences and by the knowledge shared with others in the course of interaction. The social construction of reality in everyday life – interaction between the social and the individual, connections between objective reality and subjective meaning – has been the central idea of social constructionist theories (Berger and Luckmann 1966/1991; Spector and Kitsuse 1987; Searle 1995). At present, at least two different constructionist schools of thought can be identified within research addressing social problems: ‘strict’ and ‘contextual’ con-structionism. The two approaches are divided according to the different status they give to the conditions under which claims-making processes take place (Lagerspetz 1996 :12). ‘Strict’ social constructionism takes the position of a supposedly objec-tive perspective in refusing to relate itself either to the social conditions against which the claims may be interpreted, or to the possible interests and values behind

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such claims. As a result, it advises the study of social problems to focus entirely on the claims-making processes themselves, ostensibly presuming nothing about their social context. In contrast, the ‘contextual’ approach represents the interactionist and ethnomethodological tradition, stating that social problems themselves are re-sults of a subjective definition process, which itself can be of interest and which needs to be placed in the context of what is known – however vaguely – about val-ues, interests and objective conditions.

With regard to the wider scope of social phenomena, the ‘contextual’ approach should be discussed: It seems to lie closer than the ‘strict’ approach to the construc-tionist sociology of knowledge originally suggested by Berger and Luckmann (1966/1991). The authors have described the basis of their theory as follows: ‘Our view of the nature of social reality is greatly indebted to Durkheim and his school in French sociology, though we have modified the Durkheimian theory of society by the introduction of a dialectical perspective derived from Marx and an emphasis on the constitution of social reality through subjective meaning derived from Weber’ (28-29). In other words, Berger and Luckmann believe that they have shown a way in which the theoretical positions of Weber and Durkheim can be combined in a comprehensive theory of social action without losing the inner logic of either. The central question for sociological theory as put by Berger and Luckmann is as fol-lows: How is it possible that subjective meaning becomes objective facticity?

According to Berger and Luckmann (1966/1991), everyday life presents itself as a reality which is interpreted by individuals and is subjectively meaningful to them as a coherent world. It is a world that originates in their thoughts and actions and is maintained as real by these (33). While it is possible to say that individuals have a nature, it is more significant to say that they construct their own nature, or more simply, that they produce themselves. Human behaviour is a product of the individ-ual’s own sociocultural formations rather than of a biologically-fixed human nature (67). Biological facts serve as a necessary precondition for the production of social order (70). The organism and, even more, the self cannot be adequately understood apart from the particular social context in which they were shaped. Human activity can be described as conduct in the material environment and as an externalization of subjective meanings (68). The question of psychological status cannot be decided without recognising the reality-definitions that are taken for granted in the social situation of the individual. Hence, the act of attempted suicide becomes more intel-ligible if we endeavour to understand suicidal individuals’ ways of constructing their everyday reality.

The viewpoint of ‘strict’ constructionism is somewhat different. For our purposes, this approach is relevant mainly when focusing on the practices of institutional actors in defining and categorising behavioural acts as suicide attempts. Spector and Kitsuse (1987) stated that social problems exist only through the enterprises of groups or individuals who create them (161). The authors’, as well as Searle’s (1995), understanding of the construction of social reality helps to conceptualise how attempted suicide as a social fact exists. For social facts, the attitude that soci-

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ety takes toward the phenomenon is partly constitutive of the phenomenon (Searle 1995 :33). An institutional social fact cannot exist in isolation. For example, the status of being a citizen has associated with it a whole range of functions and differ-ent societies may differ radically in the rights and obligations of citizenship. That is also true for attempted suicide. Being suicidal is a reality for a person attempting suicide, but it becomes a social fact with all its consequences only if recognised, reflected and interpreted as such by society. Most commonly, attempted suicide becomes a social fact as soon as it is identified and registered in the health care system by professionals according to a valid codification system (for example, the ICD-10). After doing this, harming him- or herself counts as a suicide attempt. In this way, health care professionals’ common sense, professional knowledge and skills as well as attitudes construct a case of attempted suicide. Something is a sui-cide attempt because it is believed and agreed to be a suicide attempt. Further, being recognised as a social fact, a suicide attempt entails different consequences in dif-ferent societies concerning treatment, rehabilitation and referral.

Summarizing these general theoretical underpinnings, in order to understand at-tempted suicide as a social phenomenon, the culture, objective everyday reality, subjective meaning of reality and interaction between these constructs should all be considered.

ATTEMPTED SUICIDE

The development of suicidal behaviour has been characterised by a model of suici-dal process with continuously increasing intensity. Suicidality is a continuum from the lowest (weariness towards life, suicidal ideation) to the highest (serious suicide attempt and completed suicide) level of suicidality (Maris et al. 2000; Wasserman 2001b; Bertolote et al. 2009; Bertolote and Wasserman 2009).

A considerable lack of consensus exists surrounding any universal conception and appropriate terminology applicable for all suicidal acts with a non-fatal outcome. While some researchers consider non-fatal suicidal acts as failed suicides (Farmer 1988) others consider it as a way to seek attention (Maris 1981). Different research-ers have tried to provide the most adequate term for a non-fatal suicidal act – sui-cide attempt, parasuicide, intentional self-harm, deliberate self-harm, non-fatal sui-cidal behaviour (Kreitman 1977; ICD-10 1990/2007; Platt et al. 1992; O'Caroll et al. 1996; Hawton et al. 2003; De Leo et al. 2004; Silverman 2006a; Silverman et al. 2007a; 2007b). What is more, all these terms have been defined in different ways and, so far, no consensus has been reached between suicidologists on the best appli-cable term.

Generally speaking, a suicide attempt relates to actions taken against oneself and without fatal outcome, but with a clear intention of self-destruction. According to Silverman (2006a), any meaningful definition of a suicide attempt should contain a high likelihood of death and true intent to kill oneself. However, not all authors have the same view on the intentional and motivational aspects of non-fatal suicidal

19

acts. Becks et al (1974a) described a suicide attempt as a wilful, self-inflicted, life-threatening act resulting in physical injury but not in death and it does not require suicidal intent. Maris (1981) claimed that the goal of a suicide attempt is manipula-tion and attention seeking. Throughout history, the concept of a ‘cry for help’ has been applied as an explanation for suicide attempts (Stengel 1962; De Leo et al. 2004). Attempted suicide has also been presented as a certain form of conscious or subconscious communication addressed to others and a sort of alarm signal, indicat-ing an appeal for help (De Leo et al. 2004). The motive is to elicit certain expected reactions from the environment, in that others should express more love and care towards the individual (Stengel 1964). Williams and Pollock (2000) provided a psychological model entitled ‘cry for pain’ and considered suicidal behaviour more as a ‘cry for pain’ than a ‘cry for help’. This model contains more reactive charac-teristics than communication motives. Suicidal behaviour presents an escape from pain and occurs in situations where the person feels trapped.

In order to solve the dilemma between the terms ‘attempted suicide’ and ‘deliberate self-harm’, Kreitman and colleagues (1969; 1977) suggested the term ‘parasuicide’. They considered ‘parasuicide’ to be a more descriptive term and one that could cover all deliberate non-fatal acts of self-harm, without any implication about inten-tion to die. It describes events ‘in which the person simulates or mimics suicide, in that he [sic] is the immediate agent of an act which is actually or potentially physi-cally harmful to himself [sic]’ (Kreitman et al. 1969).

Researchers from Ireland, the UK, Australia and New Zealand prefer using the term ‘deliberate self-harm’. It is an act of non-fatal, self-destructive behaviour that oc-curs when an individual’s sense of desperation outweighs their self-preservation instinct (Mitchell and Dennis 2006). Deliberate self-harm includes intentional self-poisoning or self-injury, irrespective of motivation (Hawton et al. 2003; Silverman 2006a) and is associated with varying levels of suicidal intent and a wide variety of motives (McAuliffe et al. 2007). Kreitman and colleagues (1969) disagree with the usage of the term ‘deliberate self-harm’ for non-fatal suicidal acts. They claim that ‘terms such as deliberate self-harm, self-injury or self-poisoning neglect the very real association that exists between attempted suicide and completed suicide’ (De Leo et al. 2004).

A review of commonly used alternative definitions of nonfatal self-harm behaviours was recently published by Silverman (2006b). He identified four definitions of sui-cide attempt (O'Caroll et al. 1996; National Strategy for Suicide Prevention 2001; Goldsmith et al. 2002; AAS/SPRC 2006), two definitions of deliberate self-harm (Hawton et al. 2003; AAS/SPRC 2006), one definition of non-fatal suicidal behav-iour (De Leo et al. 2004), one of suicidal act (National Strategy for Suicide Preven-tion 2001) and one of parasuicide (Platt et al. 1992). In addition to the terms in-cluded in Silverman’s review, there is also the term ‘intentional self-harm’, intro-duced by the ICD-10 (1990/2007).

These alternative terms and definitions include certain similar but also certain dif-ferent components (Table 1). All of them are acts with a non-fatal outcome, which

20

distinguishes them from suicides with a fatal outcome. No matter what term is in use, they are all intentionally (deliberately) self-inflicted, which distinguishes them from accidents and other external injuries. The terms ‘deliberate self-harm’ and ‘intentional self-harm’ consider factual self-harm (injury or poisoning) as an obliga-tory component of the definition. The terms ‘suicidal act’ and ‘suicide attempt’ include intention to die or to kill oneself as a mandatory component of the defini-tion. ‘Parasuicide’ and ‘non-fatal suicidal behaviour’ emphasize the non-habitual aspect of the nonfatal self-harm behaviour. Within the WHO SUPRE-MISS study, the description given by the International Classification of Diseases, 10th edition (1990/2007) was in use as an operational term: ‘intentional self-harm’ (Codes X60-X84, Chapter XX), which includes ‘purposely self-inflicted poisoning or injury; and suicide (attempted).’

Table 1. Terms (ICD-10 1990/2007; Silverman 2006b) and components of nonfatal self-harm behaviours

Non

-fat

al o

utco

me

Inte

ntio

nal (

delib

erat

e)

self-

infli

ctio

n

Self-

harm

(inj

ury,

po

ison

ing)

Non

-hab

itual

beh

avio

ur

Inte

ntio

n to

die

Des

ire to

evo

ke c

hang

es

Deliberate self-harm (AAS/SPRC 2006)

Yes Yes Yes

Deliberate self-harm (Hawton et al. 2003)

Yes Yes Yes

Intentional self-harm, suicide (attempted) (ICD-10 1990/2007)

Yes Yes Yes

Suicidal act (National Strategy for Suicide Prevention 2001)

Yes Yes Yes

Suicide attempt (AAS/SPRC 2006) Yes Yes Yes

Suicide attempt (Goldsmith et al. 2002)

Yes Yes Yes

Suicide attempt (National Strategy for Suicide Prevention 2001)

Yes Yes Yes

Suicide attempt (O'Caroll et al. 1996) Yes Yes Yes

Parasuicide (Platt et al. 1992) Yes Yes Yes Yes

Non-fatal suicidal behaviour (De Leo et al. 2004)

Yes Yes Yes Yes

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SUICIDAL INTENT

Suicidal intent is an essential component of any definition of suicide and suicidal behaviour. This is primarily because it permits a distinction to be drawn between accidental and suicidal behaviour (Andriessen 2006). Suicidal intent has been de-fined as the seriousness or intensity of a person’s wish to terminate his or her life (Beck et al. 1974a). The term ‘level of suicidal intent’ is used to describe the inten-sity of a death wish (Hjelmeland and Hawton 2004). Researchers report that the terms ‘motives’ and ‘intentions’ are often used inconsistently (Hjelmeland and Knizek 1999a; Andriessen 2006; Silverman 2006a). Hjelmeland and Knizek (1999a) suggest that intent is more connected to an act aimed at changing the future and to achieve what the person desires. Motives are related to the ‘reason for the desire’.

Suicidal intent evolves during the suicidal process and the levels of suicidal intent at different stages of the suicidal process may vary. According to Durkheim (1897/2002), intent is too intimate a thing to be anything more than vaguely inter-preted by another; it even escapes self-observation. Suicidal intent consists of a consciously expressed wish to be dead but there are also non-suicidal conscious or unconscious purposes, such as trying to manipulate others or escape from an intol-erable situation (Michel et al. 1994; Hjelmeland 1995; Hjelmeland and Knizek 1999b; Hjelmeland and Hawton 2004; Andriessen 2006). Moreover, suicidal behav-iour has clear aspects of verbal communication but nonverbal suicidal communica-tion also expresses suicidal intent, one example being the particular way in which a suicidal act is carried out, especially in the presence of others (Lester 2001; Wasserman 2001b).

Subjectively meaningful suicidal intent becomes objectively available and meaning-ful for others after reflecting on it in an objective way. Although difficult to be ob-served, aspects of suicidal intent and verbal or non-verbal suicidal communication can be measured by means of self-rated single questions or specific self-rated scales. Psychometric scales are available to measure levels and various aspects of suicidal intent. One of the best-known scales, the Beck Suicide Intent Scale (BSIS), is not a suicide-risk scale as such, but rather a scale designed for use in research studies to classify suicide attempters (Beck et al. 1974a; Beck et al. 1979; Bech et al. 2001). A comparable scale, the Pierce Suicidal Intent Scale (PSIS), was devised to measure the severity of suicidal intent among suicide attempters (Pierce 1977). Pierce’s intention was to design and test a more objective scale for measuring suici-dal intent than the BSIS but the outcome was merely a modification.

WELL-BEING

In postmodern society, there is a clear shift from survival values toward well-being values (Inglehart 1997). The concept of well-being is complex and multidisciplinary in nature, comprising different dimensions, both on an individual and societal level – economic, social, physical and psychological (Diener and Lucas 2000; Helliwell

22

and Putnam 2004; Huppert and Baylis 2004). One possible way to define well-being relevant to different societal levels, given by Huppert et al (2004), is: ‘a posi-tive and sustainable state that allows individuals, groups and nations to thrive and flourish’. Diener (1984) distinguished between three ways of formulating the defini-tion of well-being: first, in a normative way, by external criteria defining what is desirable in society; second, in a cognitive way, by a person’s self-assessment of their life in positive terms (life satisfaction); third, in an affective way, stressing pleasant emotional prevalence over negative affect. These last two constitute sub-jective well-being.

According to Ryan and colleagues (2001; 2008), the concept of well-being refers to optimal psychological functioning and experience. How we define well-being influ-ences our practices of government, teaching, therapy, parenting and preaching, as all such endeavours aim to change humans for the better and thus require some vision of what ‘better’ is. Ryan distinguishes between two approaches to subjective well-being: hedonic and eudaimonic. The hedonic view equates well-being with positive emotions – pleasure and happiness – and is concerned with the experience of pleasure versus displeasure or pain. The term eudaimonia refers to well-being as distinct from happiness per se. The eudaimonic conception of well-being calls upon people to live in accordance with their true self, to realise valued human potential and to feel intensively alive and authentic. Finally, he claims that perhaps the con-cern of greatest importance is the relationship between personal well-being and the broader issues of the collective wellness of humanity. As individuals pursue aims they find satisfying or pleasurable, they may create conditions that make more for-midable the attainment of well-being by others.

As stated by Helliwell and Putnam (2004) the ultimate ‘dependent variable’ in so-cial science should be human well-being, and in particular, well-being as defined by individuals themselves, or ‘subjective well-being’. Only in recent years have psy-chologists, economists and others begun to demonstrate that subjective well-being can be measured with reliability and validity, using relatively simple self-rated questions about ‘happiness’ and ‘life satisfaction’.

There is rather little research available, to the best of the researcher’s knowledge, about the role of well-being in understanding suicidal behaviour. An ecological study confirmed an inverse association between the suicide rate and life satisfaction and happiness as indicators of population well-being (Bray and Gunnell 2006). A relatively new instrument to measure the subjective level of people’s wellbeing is the WHO well-being index (WHO-5), developed by Bech in the 1990s (WHO 1998). The five statements of the WHO-5 are supposed to measure the pure subjec-tive psychological feeling of a person about his or her well-being. The WHO-5 has been found to be a sensitive and easily used instrument for depression screening in primary care (Bonsignore et al. 2001; Hegerl and Althaus 2003; Henkel et al. 2003; Löwe et al. 2004), although it also reflects aspects other than the simple absence of depressive symptoms (Heun et al. 1999; Bech et al. 2003; Kessing et al. 2006). The need to assess the utility of the WHO-5 in the context of detecting suicidal ideation

23

has been pointed out (Awata et al. 2007). As Helliwell and Putnam (2004) point out, ‘[t]he fact that the suicide data and the measures of life satisfaction show re-markably similar structures, especially with respect to the effects of social capital, thus represents a strong confirmation of the subjective well-being data.’

RELIGIOSITY

Koenig and colleagues (2001) have defined religion as an organised system of be-liefs, practices, rituals and symbols designed to facilitate closeness to the sacred or transcendent. However, religion is a wide concept comprised of different dimen-sions. Koenig et al (2001) identified twelve dimensions of religion: religious belief, religious affiliation and denomination, organisational religiosity, non-organisational religiosity, subjective religiosity, religious commitment/motivation, religious ‘quest’, religious experience, religious well-being, religious coping, religious knowledge and religious consequence. The present dissertation focuses on three dimensions of religion – religious denomination, organisational religiosity, and subjective religiosity – and its associations with suicidal behaviours.

Durkheim (1897/2002) illustrated the protective effect provided by religious de-nomination by way of social integration and regulation in the lower suicide rates reported in Catholic countries compared with Protestant countries. According to him, religion protects an individual against the desire for self-destruction, not due to the special nature of religious concepts, but because it creates a society with a col-lective credo. A comparison between Islam and Christianity has shown that the strong degree of integration between the individual and society developed by fol-lowers of the Islamic tradition has a moderating effect on the suicide rate (Simpson and Conklin 1988; Bertolote and Fleischmann 2002). Although several studies have supported Durkheim’s classic findings (Dervic et al. 2004; Faria et al. 2006), others doubt the effect of religious denomination as a measure of religious integration and regulation in the contemporary world (Neeleman et al. 2004; Moreira-Almeida et al. 2006), partially due to the growing convergence of Catholicism and Protestant-ism (Stack 1983). Regardless of type, religion in general may provide protection against suicide (Breault 1986) and the presence or absence of religious denomina-tion may be more useful than the evaluation of an association between specific religious denominations and suicidal behaviours (Dervic et al. 2004; Faria et al. 2006).

Different religions have different views on suicidal behaviour. In most known relig-ions of the world, suicide is condemned, especially in the three monotheistic relig-ions of Judaism, Christianity and Islam. However, the strength of this condemnation has varied over time and within the religions themselves. Within Christianity, the conservative church members (Catholic and Orthodox) have been the most outspo-ken against suicide with the sixth commandment (‘Thou shall not kill’) used as the official Christian statement prohibiting suicide (Pescosolido and Georgianna 1989; Kelleher et al. 1998). Both Hindus and Buddhists are more ambivalent in their atti-

24

tude towards suicidal behaviours. They believe in karma, which facilitates the idea that putting an end to one’s life is not the final step (Bolz 2002). The Hindu religion tolerates suicide in situations when a person is considered socially dead already, such as serious handicap (Tousignant et al. 1998). Islam is arguably much firmer about the sinfulness of suicide than Hinduism and Buddhism, and even Christianity (Lester 2006). The Islamic doctrine regarding suicide is well known: persons taking their own life will be denied entry into heaven. Suicide is considered a sin and sub-sequently a crime but it is also a shameful act within the family and subsequently must be concealed (Khan and Reza 2000). Still, the Islamic religion condemns on one hand and forgives on the other, as suicide victims are often seen as mentally ill (Simpson and Conklin 1988). A separate social construct known in the context of Islam is suicide terrorism, as suicide terrorists do not appear to be truly suicidal and belong to a subgroup of the terrorist population (Townsend 2007).

Regardless of denomination, actual church attendance can be used as an indirect indicator of religious commitment and, in turn, can be considered protective against suicide (Breault 1986; Kelleher et al. 1998). Church, mosque or other important religious attendance (i.e., how often someone attends religious meetings) is one of the most commonly used questions to investigate the level of religious involvement (Koenig 2005; Moreira-Almeida et al. 2006). Several studies have revealed that religious commitment, expressed in church attendance, is closely and inversely associated with suicidal behaviours (Stack and Lester 1991; Siegrist 1996; Duber-stein et al. 2004; Musick et al. 2004; da Silva et al. 2006). However, exactly which elements of religious participation reduce the risk of suicide cannot be easily dis-cerned. Pescosolido and Georgianna (1989) claimed that religious and other net-work ties alike have both integrative and regulative aspects and act, therefore, as important sources of social and emotional support. Another study showed that visit-ing or talking with friends or relatives did not reduce the likelihood of suicide but frequent participation in religious activities did, which suggests that something more specifically intrinsic in religious identity might be responsible for decreasing suicide risk (Nisbet et al. 2000).

A question widely used to investigate the level of religious involvement and the importance of religion in someone’s life is subjective religiosity (Moreira-Almeida et al. 2006). In postmodern societies, personal beliefs are at least as relevant as integration into religious institutions when explaining individual and group behav-iours (Stack 1983; Inglehart 1997; Neeleman 1998). The dimension of subjective religiosity leads us closer to the concept of spirituality, which has been described as less formal and organised and more subjective, individual and inwardly directed than religiosity (Koenig et al. 2001). Spirituality outside formal religion as well as the concern for the meaning and purpose of life has begun flourishing in the post-modern era (Inglehart 1997; Hay 2002).

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RESEARCH PROBLEM AND AIMS

Sociological studies have concentrated mostly on suicide and less is known about attempted suicide as a social phenomenon. Moreover, most of the studies on at-tempted suicide are performed in developed countries and less research is available from low- and middle-income countries, especially from a global cross-culturally comparative perspective.

The current study focuses on attempted suicide as a social phenomenon and is based on the assumption that, along with the epidemiological, medical and psychological aspects of attempted suicides, sociological aspects are important as well. Moreover, not only are the structural elements of society (e.g. marriage, education, employ-ment) relevant, but so too are the post-material values, cultural systems, interactions in constructing everyday reality and subjective meanings given by individuals to their acts.

This dissertation is based on four articles dealing with the same empirical material. They are all concerned with the subject of attempted suicide, albeit from slightly different perspectives, and are linked with each other through a common theoretical framework—that is, the one provided in the previous section.

The aims of the current dissertation are:

(1) To provide a qualitative description of the sites included in the WHO SUPRE-MISS study in respect to the sociocultural context of suicidal behaviours. These qualitative descriptions detail the sociocultural background conditions in the societies where the quantitative data on attempted suicides has been collected. The descriptions comprise existing religious systems, rituals and ceremonies regarding death and the sociocultural context and attitudes towards suicidal be-haviour;

(2) To describe the main characteristics of suicide attempters and their identifica-tion and referral routines at emergency departments of general hospitals in spe-cific culturally diverse low- and middle-income countries from around the world (Article I). The sites/countries included in the WHO SUPRE-MISS study were selected by WHO experts from the regions where less research on at-tempted suicides is available;

(3) To investigate whether religiosity, assessed across three dimensions – religious denomination, organisational religiosity, and subjective religiosity – could serve as a protective factor against attempted suicide from a cross-cultural per-spective (Article IV). Religion as a social institution has different dimensions and the assumption is that the subjective meaning of religiosity might have an even stronger protective effect than structural and formal religious dimensions, such as belonging to any particular denomination or attending church or other place of worship;

(4) To characterise the severity of attempted suicide by extracting the components of suicidal intent and analysing levels of suicidal intent by gender, age and ex-

26

ternal variables indicative of the severity of attempted suicide (Article III). The assumption is that the subjective meaning given to the suicidal act by a suicide attempter, as measured by the self-reported level of suicidal intent, is an impor-tant piece of information about the severity of attempted suicide, in addition to objective external observations;

(5) To analyse the association between the severity of a suicide attempt, measured by the suicidal intent scale, and the characteristics of the emotional status of suicide attempters, measured by depression, hopelessness and well-being scales in different gender and age groups; to test the applicability of well-being, as measured by the WHO-5 in suicide risk assessment (Article II). Subjective psy-chological well-being as an important post-material value is believed to have high relevance in the assessment of the severity of attempted suicide.

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RESEARCH DESIGN, METHODS AND DATA

OVERALL RESEARCH DESIGN AND PARTICIPATING SITES

In 2000, WHO launched the Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS), the aim of which was to increase knowledge about suicidal behaviour and the effectiveness of interventions on suicide attempters in culturally diverse places around the world. Its main objective was to reduce the mortality and morbidity associated with suicidal behaviour.

SUPRE-MISS had three components (Fleischmann et al. 2009):

1. Intervention study A clinical survey with semi-structured face-to-face interviews with suicide at-tempters seen at emergency-care departments in defined catchment areas (Fleischmann et al. 2005) and a randomised clinical trial to evaluate treatment strategies (Fleischmann et al. 2008);

2. Community survey A community survey with semi-structured face-to-face interviews with ran-domly selected community members to identify suicidal ideation in the same catchment areas (Bertolote et al. 2005; Bertolote et al. 2009)

3. Community description A qualitative community description covering the sociocultural characteristics and contexts of the target communities (Bertolote et al. 2005).

The participating sites were selected by WHO among low- and middle-income countries and these represent all WHO regions globally: Campinas (Brazil), Chen-nai (India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Vietnam), Karaj (the Islamic Republic of Iran), Tallinn (Estonia) and Yuncheng (People’s Republic of China). Within each site, a catchment area with a population above 250,000 in-habitants was selected. The catchment areas of the sites were urban areas, that is, either the whole city (Campinas, Colombo, Durban, Karaj and Tallinn) or a sector of the city (South Chennai and the Dong Da district of Hanoi), except for Yuncheng which comprised a rural area. The size of the target population of the catchment area ranged between 350,000 and 2,000,000.

In Estonia the study was conducted by the Estonian-Swedish Suicidology Institute (ERSI). The author of the current dissertation participated in the study as a local project manager and interviewer. One of the supervisors, Prof. Dr. Airi Värnik, participated as the site leader and principal investigator and is a member of the WHO expert group which developed the SUPRE-MISS study concept and design. The SUPRE-MISS methodology and instruments were translated, adapted to local conditions and pilot tested in all participating sites. The research protocol was ap-proved by the relevant ethics committee in each site. The Tallinn Medical Research Ethics Committee approved the Estonian study (decision no. 203, August 22, 2001).

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EMERGENCY-CARE DEPARTMENTS AND SETTINGS FOR THE COMMUNITY SURVEY

The study on attempted suicides was carried out in one or more emergency-care departments from the participating sites. In Campinas (Brazil), it was the Hospital das Clinicas, Universidade Estadual de Campinas. In Chennai (India) it was the Government Royapettah Hospital. In Colombo (Sri Lanka) it was the acute care wards of the National Hospital Sri Lanka. In Durban (South Africa), the Addington, King Edward VIII, RK Khan and Prince Mshiyeni Memorial hospitals were in-volved in the study. In Hanoi (Vietnam), the Bach Mai, Dong Da, Saint Pault and Thanh Nhan hospitals participated. In Karaj (the Islamic Republic of Iran), the Emam, Madani, Ghaem and Rajaee hospitals were involved. In Tallinn (Estonia), the North Estonian Regional Hospital (the Tallinn Mustamäe Hospital and the Tal-linn Psychiatric Clinic) participated. In Yuncheng (People’s Republic of China), it was the Yuncheng County Hospital. These hospitals served the respective catch-ment areas of the participating sites.

At least 500 randomly selected community members from the same catchment areas were interviewed for the community survey. The survey covered the general popu-lation of the respective community. In each site, the most adequate source and strat-egy for sampling was chosen: In Campinas and Colombo, the sampling frame was the list of residents from census tracts; in Chennai, Durban and Hanoi, the street index was used; in Karaj, it was done by way of the electric power company code; and in Tallinn the general practitioners’ lists were used. The sampling strategies applied varied, from simple random to multi-stage, cluster and stratified sampling, all of which are probability sampling methods utilizing different types of random selection. Sampling procedures are described in detail elsewhere (Bertolote et al. 2005). These community members also served as controls for the suicide attempters for Article IV.

SUBJECTS AND DATA COLLECTION PROCEDURE

All suicide attempters identified by medical staff in emergency-care settings be-tween January 2002 and January 2004 (in Hanoi up to April 2004) within the de-fined catchment areas were invited to participate in the study. Once medically sta-ble, the suicide attempters were asked to fill in a consent form and those who agreed were then interviewed. Interviews were conducted face-to-face and took place, as a rule, at the respective emergency-care departments. The interviewers were clinically experienced and specially trained psychiatrists, medical doctors, psychologists and/or psychiatric nurses. A total of 4,314 subjects were included in the intervention study. Their distribution by site is given in Table 2 and gender and age characteristics are given in Table 3 and in Article I.

The community members included in the study were chosen from the same catch-ment area and interviewed between 2002 and 2004. All respondents in the commu-nity survey provided informed consent. All information was self-reported and, in

29

most cases, interviews were conducted face-to-face with the exception of Colombo, where the questionnaire was mailed to respondents. The interviewers were nurses, psychologists, medical students, medical doctors, family health workers and public health professionals. All were previously trained in the use of the SUPRE-MISS survey instrument. A detailed description of the subjects and results is published elsewhere (Bertolote et al. 2005; Bertolote et al. 2009). The distribution of subjects by site is given in Table 2 and gender and age characteristics are given in Table 3.

Table 2. Total number of subjects participating in the SUPRE-MISS study

Site

Com-munity survey

Intervention study Intake part of questionnaire

All parts of questionnaire

Campinas (Brazil) 516 162 162 Yuncheng (People’s Republic of China) - 120 120 Tallinn (Estonia) 500 469 332 Chennai (India) 500 680 680 Karaj (the Islamic Republic of Iran) 504 945 632 Durban (South Africa) 500 570 570 Colombo (Sri Lanka) 684 1067 300 Hanoi (Vietnam) 2280 301 143 TOTAL 5484 4314 2939

Table 3. Gender and age characteristics of subjects participating in the SUPRE-MISS study

Site

Community survey Intervention study (intake) Male-female ratio

Age Male-female ratio

Age

Mean Min Max Mean Min Max Campinas (Bra-zil) 0.62 41.5 14 88 0.55 32.6 12 80

Yuncheng (Peo-ple’s Republic of China)

- - - - 0.48 34.6 14 69

Tallinn (Estonia) 0.95 42.7 15 84 0.52 32.6 15 89 Chennai (India) 2.09 27.1 14 62 0.95 26.2 10 75 Karaj (the Is-lamic Republic of Iran)

0.59 28.7 14 73 0.72 25.3 11 78

Durban (South Africa) 0.85 38.7 6 83 0.38 25.5 13 65

Colombo (Sri Lanka) 0.88 40.3 12 84 0.80 26.9 12 85

Hanoi (Vietnam) 0.93 39.9 10 96 0.41 25.8 13 76

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According to the study protocol, the qualitative community description had to be conducted by a person experienced in the field. In most of the participating sites, the community description data was collected by the principal investigators. The exception was Colombo, where the questionnaire was completed by a social an-thropologist. In answering the items, the objective recorded data in combination with information gathered from key informants or focus group members were used. The data describe participating sites as at 2002. In some cases, it was impossible to extract a strictly site-specific description and the data are presented for the whole country, mostly in those cases where the country is more or less monocultural in structure. Detailed community description data were available for analysis from six participating sites: Campinas (Brazil), Chennai (India), Colombo (Sri Lanka), Ha-noi (Vietnam), Karaj (the Islamic Republic of Iran) and Tallinn (Estonia).

INSTRUMENTS

The questionnaire, based on the European Parasuicide Study Interview Schedule (EPSIS) (Kerkhof et al. 1999) of the WHO/EURO Multicentre Study on Suicidal Behaviour was translated and pilot-tested in each country. It included a detailed intake section comprising the method of the suicide attempt, physical consequences, the type of care and referral as determined by the medical staff, as well as sociode-mographic information and results from different psychological scales (WHO 2002; Fleischmann et al. 2009). The SUPRE-MISS questionnaire for suicide attempters is included in Appendix 1 and the SUPRE-MISS community survey questionnaire appears in Appendix 2.

In Articles II and III, a revised version of the original Pierce Suicidal Intent Scale (PSIS) was used in the measurement of suicidal intent (Pierce 1977; WHO 2002). The scale consisted of 12 questions with a possible total score ranging from 0 to 24: the higher the score, the more severe the suicide attempt.

In Article II, the following scales were used for measuring the psychological status of suicide attempters:

1. The occurrence of depression was assessed using the means of the 21-item Beck Depression Inventory (BDI) (Beck et al. 1961). The possible range of scores was 0 to 63. A higher score refers to a more severe depressive status.

2. Negative attitude towards the future was assessed on the Beck Hopelessness Scale (BHS) (Beck et al. 1974b) and on its one-item modification, the Aish & Wasserman scale (Aish and Wasserman 2001). The original scale consists of 20 statements to be rated dichotomously (true vs. false) and the total score has a theoretical range of 0 to 20. The Aish & Wasserman scale consists of one statement (‘‘My future seems dark to me’’). To be in line with other scales used which are measured in the opposite direction, in the current research, a higher score refers to more severe hopelessness.

3. Assessment of well-being was performed using the WHO well-being index (WHO-5) (WHO 1998). The five statements presented (‘I have felt cheerful

31

and in good spirits’, ‘I have felt calm and relaxed’, ‘I have felt active and vig-orous’, ‘I have felt fresh and rested’, ‘My daily life has been filled with things that interest me’) were assessed on a 6-score scale (from never to always), with a possible total score varying from 0 to 25. A higher score refers to greater well-being.

For Article IV, both the suicide attempters and controls were asked the following religion-related questions:

(1) What is your religious denomination? Response choices were: none; Protestant; Catholic; Jewish; Muslim; Hindu; Greek Orthodox; Buddhist; other.

(2) How often do you go to church (or other place of worship)? Response choices were: At least once a week; once a month; 2–3 times a year; about once a year; almost never.

(3) Do you consider yourself to be a religious person? Response choices were: no; yes.

Qualitative community description data were collected by means of a separate, specially designed instrument (questionnaire) (WHO 2002; Fleischmann et al. 2009), which appears in Appendix 3. The questionnaire comprised a broad listing of sociocultural and community indices and dimensions. The content and face validity of the questionnaire were evaluated in pilot studies and adapted to the specificities of the local cultural if needed.

DATA ANALYSIS

The sociocultural indices relevant as background for the current dissertation were extracted from the qualitative community description data. The content was restruc-tured and assembled under the following subtitles: religious systems, rituals and ceremonies regarding death, sociocultural context and attitudes towards suicidal behaviour.

Statistical analyses were performed with the SPSS program (version 14.0). For categorical variables, the differences between groups were evaluated by a chi-square test. For continuous variables, the differences were evaluated by a t-test if two groups were compared or an analysis of variance (ANOVA) if three or more groups were compared.

To estimate the associations between the cases (suicide attempters) and the controls, in terms of potential risk or protective effect of religiosity, binary and multinomial logistic regression analyses were performed and an odds ratios (OR) calculated with a 95% confidence interval (95% CI). The level of statistical significance was set at α = 0.05.

To extract the factors of the Pierce Suicidal Intent Scale (PSIS), the procedure of principal components with varimax rotation was used.

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For Articles II and III, the reliability of the scales was assessed using the internal consistency coefficient, Cronbach’s alpha. The internal consistency of the Pierce Suicidal Intent Scale (PSIS) was good (Cronbach’s α = 0.77) and for the other scales very good: Beck Depression Inventory (BDI) Cronbach’s α = 0.93, Beck Hopelessness Scale (BHS) Cronbach’s α = 0.91, the WHO well-being index (WHO-5) Cronbach’s α = 0.93.

Spearman’s rank correlation coefficient was calculated to examine the strength of the relationships between different the variables.

Table 4. Description of data and analysis methods applied in the current dissertation

Article Data Methods Article I Fleischmann et al. 2005

SUPRE-MISS, 8 coun-tries 2002-2004 Suicide attempters (n = 4314)

Descriptive statistics

Article II Sisask et al. 2008

SUPRE-MISS, Estonia 2001-2004 Suicide attempters (n = 469)

Internal consistency coefficient

Cronbach’s alpha Descriptive statistics t-test Analysis of variance (ANOVA) Spearman correlation coefficient

Article III Sisask et al. 2009

SUPRE-MISS, Estonia 2001-2004 Suicide attempters (n = 469)

Factor analysis, principal components

with varimax rotation Descriptive statistics t-test Analysis of variance (ANOVA) Spearman correlation coefficient

Article IV Sisask et al. 2010

SUPRE-MISS, 7 coun-tries 2002-2004 Suicide attempters (n = 2819) Controls (n = 5484)

Descriptive statistics Chi-square test Binary and multinomial logistic re-

gression analysis

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RESULTS AND DISCUSSION*

QUALITATIVE SOCIOCULTURAL DESCRIPTION OF PARTICIPATING SITES

Some basic sociocultural indices of the SUPRE-MISS communities have been briefly presented previously by Bertolote et al (2005). Below, a more comprehen-sive and restructured description is provided.

Campinas (Brazil)

Religious systems. The main religion is Christianity; approximately 60% of the population are Catholic and about 25% Pentecostal. The places of worship are Catholic churches and Pentecostal temples. There is great religious tolerance and the various religious groups get on well.

Rituals and ceremonies regarding death. Death is seen as something tragic, in contradiction to the fact that more than 90% of the population believe in life after death. After death, the deceased is watched over for nearly 12 hours. He or she is exposed to family and friends in a coffin and, afterwards, is buried. There is no evident differentiation or discrimination in the funeral ceremonies for people who has committed suicide.

Sociocultural context and attitudes towards suicidal behaviour. Suicide is seen as an act resulting from mental illness and/or moral weakness, an attitude which is influenced by the local religiosity. Religion should repress suicide and in the Catholic and Pentecostal religions, it is seen as a serious offence that could impede ascension to heaven. Nevertheless, religion produces a consoling vision as ‘the kingdom of God is for the poor’. In the social, political and cultural context, a large social difference (with a good education being only for the privileged few) produces critical life conditions for the lower class, counterbalancing the religious influence present among members of this class with regard to suicide. The subject of suicide is common in teen popular culture, in songs of groups like ‘Legião Urbana’ and others, generating strong emotional appeal and popularity among teenagers.

Usually, suicide is condemned and seen as an act resulting from a moral disease or weakness and/or spiritual problem. The most common feelings toward a person who commits suicide are pity and moral condemnation. Toward suicide attempters, there is a lot of variation but there is usually intensified support and attention, com-bined with some criticism and hidden anger. Sometimes, the family of a suicide victim is seen socially outcast and as partly to blame for the suicide, which pro-

* References to Articles I-IV are marked as follows: (‘aa’/’bb’), where ‘aa’ refers to the page number of the current dissertation and ‘bb’ refers to the page number of the journal where the article was originally published

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duces hidden anger in the family members but, usually, support and care are intensi-fied.

Tallinn (Estonia)

Religious systems. Religious people comprise 29% of the population. The main religion is Christianity: Lutherans (46%), Orthodox (44%), Catholicism and other forms of Christianity. There are many Lutheran churches. There are no religious conflicts among groups; the community is tolerant to different religions. Religion is separated from the state but has some involvement in social services through sup-port services to victims of violence. The constitution declares religious freedom for every citizen.

Rituals and ceremonies regarding death. Community members’ perceptions of death and afterlife are ambiguous and there is a lot of ambivalence. In terms of rituals and ceremonies regarding death, burying is traditional but cremation is ac-ceptable as well. Historically there was no religious service for someone who com-mitted suicide. Nowadays, there is no difference in the burial ceremony; one can choose a religious or non-religious type of ceremony.

Sociocultural context and attitudes towards suicidal behaviour. Traditionally, in Estonia, suicide has been seen as a sin and suicide victims mourned without reli-gious ceremony. Nevertheless, because most Estonians have been Protestants (Lu-therans), attitudes toward suicide have not been as rigid as among Catholics. During the time of Soviet occupation, the Soviet Union denied religion, suppressing its role in society, which probably supported the increase in suicide rates. In national litera-ture (e.g. the novels of Anton Hansen Tammsaare, Karl Ristikivi, etc) suicide is described as one of the possible reactions to critical life events without any negative judgment. In folklore, suicide is referred to as the devil’s temptation.

In terms of people’s attitudes, in Estonia suicide is accepted if the person who committed suicide had a serious somatic illness, but euthanasia has not been legal-ised. The attitude that suicide is an acceptable end to life, for various philosophical reasons, is widespread, especially among educated young people. The general atti-tude towards a person who committed suicide is ambivalent – is it weakness or strength? On the one hand, there is the opinion that those who commit suicide are weak, irresponsible and egoistic; they choose to escape instead of solving their problems. On the other hand, people feel sorry for them and accept it with compas-sion. Previously, the general attitude towards suicide attempters was rejection. To-day, it has largely changed because of the more open discourse on the issue in soci-ety. People try to understand that there could be crisis situations in any person’s life when suicide or a suicide attempt seems to be the only solution. The conviction that those people could be helped is accepted, although they do not usually get the ap-propriate mental help with the exception of the seriously mentally disturbed. The general attitude towards the family of the person who has committed suicide is compassion and condolence. At the same time, people feel confusion; they do not

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know how to behave with the survivors and the result is avoidance. Another possi-ble response towards survivors is to lay blame. This attitude will probably also change because of the increasingly open discourse and suicide survivors’ support groups which are now established in Estonia.

Chennai (India)

Religious systems. The main religion is Hinduism (85%). Other formal religions are Islam (8%), Christianity (6%) and Sikhism. There are a large number of places of religious worship (temples, shrines, churches, cathedrals). Hindu-Muslim and Hindu-Christian conflicts do occur, but rarely.

Rituals and ceremonies regarding death. In the Hindu religion, death is followed by cremation and accompanied by 13 days of rituals and ceremonies. Apart from the usual rituals, there are special rituals performed for the person who committed suicide. The belief is that the souls are not liberated and thus left to wander around on Earth. This is why some additional rituals have to be performed: So that the tormented soul can attain bliss. Family members also partake in these rituals and generally do not avoid the ceremonies. The mourning practices of Christians and Muslims are similar to those among Christian and Muslim communities in other parts of the world.

Sociocultural context and attitudes towards suicidal behaviour. Traditionally, the attitude towards suicide in India has been inconsistent. Scriptures like Upani-shads and Vedas denounce suicide. At the same time, epics and folklore tales depict many instances of suicide and some suicides have even been glorified. The attitude has been one of non-acceptance of general suicide, but religious suicides were, historically, mostly accepted. A significant proportion–almost 11%—of suicides in India is committed by self-immolation. Around 85% of self-immolations are by women. One of the historical reasons for the high self-immolation rate could be because of ‘sati’, which existed in India. There were many instances of religious suicides in India like ‘sati’ and ‘sallekhana’ (practiced by the Jain community). Television and movies have tremendous influence over the masses and suicide is often depicted. Literature also depicts suicide, even today. The majority of works of literature portrays suicidal behaviour as a way of coping with life stressors.

Suicide is perceived as an impulsive, emotional act. Suicide is not perceived as a major health issue. It is viewed more as a social problem. People who commit sui-cide are considered as persons who brought shame to the family and hence there is rejection and anger towards the person who commits suicide. If the suicide is due to some special social reason, such as problems with a mother-in-law or daughter-in-law or a failure in love, people are more sympathetic towards them, however. There is a mix of attitudes towards a person who has attempted suicide. It is a mixture of support, anger and ridicule. There is a certain amount of rejection. Arranged mar-riages are still prevalent in India and there is hesitation in marrying into a family where suicide had occurred.

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Karaj (The Islamic Republic of Iran)

Religious systems. The official religion in the country is Islam with Shia being the official denomination. More than 98% of the population in the Islamic Republic of Iran is Muslim. Other formal religions present in the country include Christianity, Judaism and Zoroastrian. There are no significant conflicts between different reli-gious groups. There are many religious worship places in the Islamic Republic of Iran but exact data are not available at this time.

Rituals and ceremonies regarding death. Perceptions of death and the afterlife are religious in nature. They consider death as a transition from one life to another, that is, from life to the afterlife. Religious rituals and ceremonies regarding death vary from one ethnic and religious group to another. The usual burial and mourning practices are carried out for those who have committed suicide.

Sociocultural context and attitudes towards suicidal behaviour. Suicide is con-sidered a sin and a behavioural problem which is caused by a lack of belief and an inability to deal with the stresses of daily life. Religious belief has kept the rate of suicide low, although sociopolitical views and conditions mean that actual suicide rates have been kept secret. The general reaction towards a person who commits suicide is sympathy, anger, condemnation, and an attempt to keep it secret. A per-son who attempts suicide but survives is treated with sympathy, care and support; they are givien advice and sometimes criticised. Towards the family members of a suicide victim, the attitude is sympathetic and supporting and there is a willingness to help.

Colombo (Sri Lanka)

Religious systems. Sri Lanka has four major religious orientations: Buddhism (main religion), Hinduism, Islam and Christianity. Of the Christian denominations, the Catholic Church predominates, while the Methodist Church, the Anglican Church, the Baptists and others also have a presence. Interreligious conflict does not exist as a regular or recurrent pattern in the country. However, in certain spe-cific local contexts, conflicts have arisen between Buddhists and Muslims, Bud-dhists and Christians and Muslims and Hindus. Violent conflicts between Muslims and Buddhists have arisen in Colombo, mostly over issues of sacred space. Violent conflicts between Hindus and Muslims have occurred in parts of the Eastern Prov-ince, mostly in the context of Muslim opposition to the taxation imposed by the Liberation Tigers of Tamil Elam (LTTE). But these are generally political conflicts that tend to be seen as confrontations between religious groups. It would be virtu-ally impossible to give an accurate figure of the number of religious sites in the city of Colombo or the country in general.

Rituals and ceremonies regarding death. All religions practiced in Sri Lanka have the standard mourning rituals as part of their rites of passage. In the case of Buddhists and Hindus, these practices are also linked to beliefs in life after death. In

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general, Hindus and Buddhists have a strong belief in life after death. Their mourn-ing rituals, including funeral practices, take this aspect into account. In terms of religious and cultural practices, there are no restrictions on either mourning or bur-ial practices for the victims of suicide.

Sociocultural context and attitudes towards suicidal behaviour. The fact that Sri Lanka has one of the highest suicide rates in the world and that four major religious traditions are present in the country would suggest that the influence of religion on suicide has been minimal, whatever their doctrinal position on suicide might be. Traditionally, suicide has not been encouraged by any of the ethnocultural groups living in Sri Lanka. Still, ritualised political suicide has become a feature of the contemporary politics of violence, namely by way of the suicide bombers of the militant group of the LTTE. In Sri Lanka, suicide is a phenomenon largely related to modernization and the social upheaval brought about by that process, dating from the 1950s. The most common causes of suicide include failure in sexual or marital relationships, lack of success at examinations and sometimes simple arguments. The main issue that has caused an increase in suicide has been a lack of professional services and a lack of space to discuss personal matters in general (e.g. love, sex, marital problems) within conventional family structures. Furthermore, the notion of shame over-determines many issues. Currently, despite the fact that suicide is one of the main social problems of the country, songs, literature, film and theatre do not deal with suicide as a mainstream issue, although suicide can be involved as a sec-ondary theme. This is indicative of society’s lack of inclination to deal with this in public. The exceptions to this rule are the LTTE songs and theatre that glorify the ritualised suicides of its members as a political weapon. The only literature of the ancient (pre-colonial) period that dealt with suicide are the Hindu epics, particularly with regard to notions such as chastity and sati. Here, suicide was offered as a pre-scriptive end to life under very specific circumstances.

Within the cultural traditions of Sri Lanka, suicide has not been seen in any positive light under any circumstances. Thus, even relatively reasonable or rational practices such as euthanasia under controlled conditions are not ideologically acceptable to most people. The exception is the highly ritualised and almost religious-like accep-tance of suicide as a political weapon within the LTTE. This has been possible un-der conditions of extreme social and political control within this group and the kin of suicide bombers are well looked after by the LTTE. Generally, suicide is seen like any other extreme misfortune of a personal nature that might befall a family. As such, on one level, suicide is treated with sympathy rather than with condemnation or anger, but on another level, families where suicide or attempted suicide have taken place would like to keep that information out of public circulation if possible. The reason for this attitude is the strong notion of shame that governs all cultural communities in the country and committing suicide or attempted suicide might mean that something is wrong in the family. Attitudes towards suicide attempters depend on the specific circumstances. There is always a sense of guilt within the family. Caring and support would depend on what a family or community is capa-

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ble of providing in terms of resources and the knowledge available to them. Profes-sional help is generally not easily accessible in Sri Lanka, particularly in rural sec-tors and in the north-eastern provinces devastated by war. It is not uncommon to perceive survivors of attempted suicide as ‘weak’. Towards family members of the suicide victim, there is a general sense of sympathy. But there are also lingering thoughts as to what lead to the suicide and the resulting gossip.

Hanoi (Vietnam)

Religious systems. Vietnam is a highly secular country where most of the people are non-religious. The two main religions in Hanoi are Buddhism and Catholicism, but no religious affiliation patterns or rates are recorded. Hanoi has Buddhist pago-das, temples from various cults, Catholic churches, Protestant churches, and so on. No major religious conflicts occur between different groups.

Rituals and ceremonies regarding death. Many Vietnamese live according to the principles of Buddhism and believe that there is another life after this one. How-ever, according to Confucian concepts, the current life is more important. Religious rituals and ceremonies after death are the usual religious rituals for Christians, in-cluding ceremonies at Christian churches, while the majority of others practice traditional rituals and ceremonies at home and some at pagodas. The burial and mourning practices in Vietnam for someone who has committed suicide are not different in comparison with those for other persons.

Sociocultural context and attitudes towards suicidal behaviour. The attitudes of Vietnamese people towards the act of committing suicide are quite diverse. In gen-eral, it depends on the reason for committing suicide. Historically, there has been sympathy for the suicide of the two women heroes, Trung Trac and Trung Nhi, who jumped into the Hat river when they were defeated by Chinese invaders. But the traditional concept condemns suicide because people believe that those who commit suicide are weak and not able to carry out their responsibilities in this life. Vietnam used to be a Buddhist country. Buddhism has a clear concept of life and death: ‘This life is just a journey, just as living in another house while death is the return to the real house.’ Some bonzes (Buddhist monks) have the ability to die by stopping their breathing, such as the two bonzes in the Dau pagoda; they sat to pray until their death and their bodies have been preserved until now. Recently, Thich Quang Duc, burned himself to defend Buddhism and has been considered a hero. But Bud-dhism does not influence the frequency of suicides. Euthanasia has not yet been accepted in Vietnam although some people express their favourable views towards it. The official concept of the ruling Communist party is materialism. Party mem-bers are not officially allowed to practice ceremonies in pagodas and churches. Nevertheless, the practice of religion is free for all people. There are songs and poems about the two sisters who jumped into the Hat River but these songs and poems are more for their heroic action in that they defended the country than for their jumping into the river.

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The general attitude of Vietnam toward a person who commits suicide depends on the reason for the suicide. Sympathy is expressed when the reason for the suicide is a common cause, such as death for defending a value. Condemnation is expressed when the reason for the suicide is not being able to bear a difficult situation, such death or a lost love. Criticism is expressed when the reason for suicide is not im-plementing a responsibility, such as not paying a debt. The general attitude in Viet-nam toward a person who attempts suicide is very complex. The community where the person lives should take care of and support the person but there are feelings of guilt and anger towards the person. The general attitude in Vietnam toward the family members of a suicide victim is a feeling of distrust.

CHARACTERISTICS OF SUICIDE ATTEMPTERS

The main characteristics of suicide attempters included in the study are described in Article I. This is the first study to provide detailed information on cases of suicide attempts from a wide range of low- and middle-income countries.

Enrolment of suicide attempters

Several cases of attempted suicide coming to the emergency-care units were unable to be interviewed for different reasons and it is difficult to estimate the exact num-ber of these non-enrolled cases. However, it is known for Tallinn that the suicide attempters enrolled in the intake interviews constituted 53% of all suicide attempt-ers seen at the emergency department during the study period (469 out of 884). Of those who did not participate, only gender and age are known. Later thorough analyses specifically addressing sampling issues revealed that, among the suicide attempters enrolled, females were slightly overrepresented (χ² = 9.7, df = 1, p = 0.002). The difference in mean age between enrolled and non-enrolled suicide-attempter groups was not statistically significant (t = 0.7, p = 0.480).

The difficulties in enrolling all eligible patients in the intake resulted from inade-quate recording of emergency room visits, intentional misreporting of suicides as accidental by patients and family members, failure of the emergency room staff to notify research staff and rapid departure from the emergency rooms of patients (before the research staff could arrive) (71/1469).

Sociodemographic characteristics

In all sites, more female than male suicide attempters presented themselves at emergency-care departments, ranging from 51% (Chennai) to 71% (Durban); in Tallinn the proportion was 66% (71/1469). The male : female gender ratio in the eight countries ranged from 1 : 1.1 to 1 : 2.6 (74/1472), which is similar to that reported in the WHO/EURO multicentre study (Schmidtke et al. 2004).

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Overall, the patients were young. This is similar to results found in developed coun-tries (Diekstra 1993; Latha et al. 1996; Schmidtke et al. 1996; Hulten et al. 2000; Thanh et al. 2005). The median age among females ranged from 21 years (Durban) to 30 years (Campinas, Yuncheng and Tallinn); and from 23 (Karaj) to 33 years (Yuncheng) among males (29 years in Tallinn). Campinas and Tallinn were the only sites where the median age of females was higher than for males (71-72/1469-1470).

Suicide attempters were more likely to be single than married among males in six countries and among females in four. In all sites, except for Campinas, female at-tempters were more likely to be married than male attempters. Divorce was com-mon among suicide attempters in Campinas (18% males, 22% females) and in Tal-linn (13% males, 15% females) (72/1470). Unlike reports from developed countries (Löhr and Schmidtke 2004), a high proportion of the subjects in this study were married at the time of their attempt, suggesting that marriage is not a strong protec-tive factor against suicide attempts in developing countries (74/1472).

With the exception of Yuncheng (where men had a higher level of educational at-tainment than women), the educational achievement of male and female suicide attempters was similar (72/1470). Except for Durban and Karaj, the majority of subjects were employed full-time or part-time at the time of admission to the emer-gency-care departments. The other common employment categories were ‘unem-ployed’, ‘housekeeper’ and ‘full-time student ’ (72/1470).

Main method of attempted suicide

The method of attempted suicide was registered according to the ICD-10 (1990/2007). Self-poisoning – which accounted for 69–98% of all cases – was the predominant method in all sites, far exceeding the other methods of ‘cutting’, ‘hanging’, and so on. In most cases, self-poisoning involved the ingestion of pesti-cides or medications. Pesticide ingestion was a more common method in Asian sites (Yuncheng, Chennai, Colombo and Hanoi) and in Campinas. More than one method, that is, a combination of methods, was rarely applied. The one exception was in Tallinn, where 11% of the suicide attempters combined self-poisoning by alcohol with another method (72/1470).

These findings strongly support earlier reports on the role of pesticide poisoning in attempted and completed suicide in developing countries (Latha et al. 1996; Eddle-ston 2000; Phillips et al. 2002a; Phillips et al. 2002b; Gunnell and Eddleston 2003; Eddleston and Phillips 2004). It has been repeatedly shown that restricting access to and the availability of the prevailing method can be effective in reducing the fre-quency of suicide attempts (Bowles 1995; Roberts et al. 2003; Mann et al. 2005) (74-75/1472-1473).

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Consequences of attempted suicide and aftercare

Suicide attempters form a pool from which many future suicides emerge (Hulten et al. 2000). This notion underlines the importance of competent and adequate as-sessment and care after attempted suicide.

The suicide attempt resulted in physical consequences and danger to life (assessed by the medical staff and understood as an indication of the clinical severity of the attempt) in more than 50% of the cases in Yuncheng, Chennai and Campinas. In the remaining sites, most subjects required a combination of medical attention or sur-gery but there was no danger to life (74/1472).

With regards to the type of care, transfer to a psychiatric institution ranged from 0% to 34%; in most of the sites it was very low (0–8% of cases), with the exception of Campinas and Tallinn. In four of the eight sites, less than one-third of subjects re-ceived any type of referral for follow-up evaluation or care. Practically no referral to any professional service was made in Yuncheng or Chennai (97–99% of cases), which reflects the non-existence of eligible referral services in these locations. In Hanoi, Colombo and Karaj, the degree of non-referral was also dominant (47–82%). In Campinas, referral was primarily made to a general health-care or primary health-care centre. In Durban and Tallinn, the patients were mainly sent to a psychi-atric out-patient clinic (74/1472).

The relative lack of professional services for referral of suicide attempters results in a situation where care is limited to somatic symptoms only. Even in those places where psychological or psychiatric services were available, psychiatric assessment and referral were not delivered in a systematic way or as part of the routine estab-lished by a European study regarding young suicide attempters (Hulten et al. 2000). In these places, the current situation leaves plenty of room for improvement in health services (75/1473).

RELIGIOSITY AND ATTEMPTED SUICIDE

Article IV investigates the effect of religiosity on suicide attempts from a cross-cultural perspective. Among other factors, religious context has been recognised as a major cultural determinant of suicidal behaviour (Stack 2000; Bertolote and Fleischmann 2002). Since Durkheim (1897/2002), research findings on the impact of religiosity on suicidal behaviour have tended to favour the idea of an inverse association and protective effect. Although exceptional and controversial findings on this issue cannot be denied, a higher level of religiosity generally indicates a lower level of suicidality.

Due to conceptual and methodological discrepancies, most studies performed so far are difficult to compare. The majority of studies has been ecological by design and relatively few individual-level findings have been reported. Furthermore, while the majority of studies has been conducted in developed countries and is based pre-dominantly on US data, less work has been done in developing countries, within the

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Eastern cultural system, or in more secularized societies (Vijayakumar et al. 2005; Colucci and Martin 2008; Stack and Kposowa 2008).

To the best of the author’s knowledge, Article IV is the first individual-level study to be conducted concurrently in culturally different sites. However, the results of the study cannot be interpreted without keeping in mind the low reliability of self-reported information about sensitive issues, the complexity of suicidal behaviour and the knowledge that religiosity is not a singular, all-powerful factor associated with suicidality. Moreover, both religion and suicidal behaviour are social con-structs and consequently dynamic across eras and cultures.

A recurring problem in sociological work is the confounding effect of the various other characteristics under investigation, which may act as buffers providing protec-tion against attempted suicide and thereby lower the significance of the effect of religiosity (Stack 2000). In Article IV, the following sociodemographic control variables available from the SUPRE-MISS instruments were included in the regres-sion analysis in order to statistically control for them: age, gender, marriage, em-ployment and education.

The study on the association between religiosity and suicide attempts has at least two limitations. First, the SUPRE-MISS study was not specifically designed to study the effects of religion on suicidal behaviours, therefore no specifically de-signed scales were included in the questionnaire. The information regarding religi-osity was collected from investigated subjects by asking direct questions. Even with clinically experienced and specially trained interviewers, the possibility remains that the self-reported information obtained could be incomplete due to respondents’ memory bias and unwillingness to report honestly on sensitive issues like religios-ity. Measuring religion with a single question is a general limitation of studies in which religion is a minor or incidental variable, rather than the primary focus (Flannelly et al. 2004). Another limitation is that religiosity has other aspects, as described by Koenig et al (2001), and these were not assessed by the SUPRE-MISS instrument. These other dimensions of religiosity, as well as spirituality, may also play an important role in some cultures.

Religious denomination

The SUPRE-MISS sites differed substantially across the religiosity-secularity spec-trum and the prevailing religious denominations across sites also varied to a large extent. Most of the major religions in the world were represented. The predominant religions were Catholicism and Protestantism in Campinas; Protestantism and Or-thodox, in addition to a great amount of people without any religious denomination, in Tallinn; Hinduism in Chennai; Islam (Shi’ite) in Karaj; various denominations without any of them prevailing in Durban; and Buddhism in Colombo. In Hanoi, most of the people reported no religious denomination (101-102/48-49).

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In Chennai, Colombo and Karaj, all controls and/or suicide attempters had some kind of religious denomination therefore the odds ratio was not calculable. A pro-tective effect of religious denomination emerged only in Tallinn, where it was more likely to be reported by the controls than the suicide attempters (OR = 0.51; 95% CI = 0.37-0.72) (102/49). Estonia is rather secular but still a predominantly Chris-tian country. In a very secular community, such as Hanoi in Vietnam, religious denomination had no effect against attempted suicide. Also in Campinas, the other Christian community, the effect of religious denomination was statistically non-significant. In Campinas, Catholicism was more frequent among the control group than among suicide attempters and Protestantism was more frequent among suicide attempters than among controls. Subsequently, religious denomination had no effect on suicide attempts in Campinas but it can be assumed that Protestantism could neutralise the protective effect of Catholicism. However, this is only speculation. This study analysed Christianity as a whole as differentiating the effect of denomi-nations within Christianity was not the issue of interest. However, a study by Bo-tega and colleagues (2005) found that, in Brazil, the lifetime prevalence of suicidal ideation among Protestants was lower than among Catholics (104/51).

Durban was the only site where religious denomination showed a risk effect (OR = 5.86; 95%CI = 3.15-10.90) (102/49). South Africa has been described as ‘‘The Rainbow Nation’’ because of its cultural diversity. There is a variety of ethnic groups and an even greater variety of cultures within each of these groups. While cultural diversity is seen as a national asset, the interaction of cultures results in the blurring of cultural norms and boundaries at the individual, family and cultural-group levels (Wassenaar et al. 1998). Subsequently, there is a large diversity of religious denominations and this does not seem favourable in terms of providing protection against attempted suicide (105/52). There is a study available which demonstrates that religious homogeneity, which increases social interaction and social bonds between individuals with shared cultural values, is inversely associated with the suicide rate (Ellison et al. 1997).

Religious denomination is one of the most widely used measures of religion in medical research. However, it is a formal construct for an individual and does not measure the extent of social interaction or other characteristics of social support and is even less informative in terms of intrapersonal or psychological perspectives (Flannelly et al. 2004).

Organisational religiosity

The second dimension of religiosity under study was organisational religiosity, that is, attending church or other place of worship weekly, monthly or yearly. The results across the different SUPRE-MISS sites were controversial. Organisational religiosity demonstrated a distinctly protective effect in Campinas, a predominantly Christian site, and in Islamic Karaj. However, no effect of organisational religiosity on suicide attempts was detected in Colombo or Durban, the two most

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heterogeneous sites of religious denomination. Somewhat confusing results on or-ganisational religiosity came from Tallinn, Chennai and Hanoi. In Tallinn, only monthly visits served as a protective factor while weekly and yearly visits were statistically non-significant. However, in Chennai and Hanoi, yearly visits had a protective effect and weekly or monthly visits remained statistically non-significant. To interpret these results, the meaning of going to church and, even more specifically, the meaning of the frequency of church attendance within different cultures needs further explanation (102-103,105/49-50, 52).

Subjective religiosity

The controls within the SUPRE-MISS study were more likely to report subjective religiosity than suicide attempters in four sites out of seven: Campinas (OR = 0.17; 95%CI = 0.10-0.29), Tallinn (OR = 0.54; 95%CI = 0.37-0.77), Karaj (OR = 0.60; 95%CI = 0.44-0.82) and Colombo (OR = 0.36; 95%CI = 0.17-0.75). In two sites (Chennai and Hanoi), the effect was statistically non-significant. It is known from previous research that, in India, subjective religiosity protects against completed suicide, not against attempted suicide (Vijayakumar 2003). The results from Hanoi can be attributed to Vietnam’s secularity, which may influence the overall way of thinking and mentality. In Durban, the risk effect of subjective religiosity was an exceptional result (OR = 2.71; 95%CI = 1.90-3.86), as was also true for the effect of religious denomination (103/50). As mentioned above, this can be explained by the cultural diversity, heterogeneity and blurring of cultural norms within the site. Subjective religiosity is a very informal and deeply subjective psychological con-struct. It may mediate health outcomes through engendering feelings of self-esteem, self-worth and other positive emotions thus providing a sense of meaning and fos-tering feelings of control and the ability to manage difficulties (Flannelly et al. 2004). In our postmodern world, subjective religiosity seems to be the crucial di-mension of religiosity (105/52).

ASSESSMENT OF THE SEVERITY OF ATTEMPTED SUICIDE

Articles II and III deal with the assessment of the severity of attempted suicide. Suicide risk assessment is an important issue and, at the same time, a complicated task. One possibility to measure the severity of a suicide attempt is to use different self-rated psychometric scales. Aspects of suicide risk like suicidal intent, depres-sion, hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure (Bech et al. 2001; Bech and Awata 2009).

The question has arisen whether a tool developed to measure suicidal intent for research purposes should be used in the same way in practice, given its inability to reflect the dynamic nature of suicidal behaviour (Lyons et al. 2000). However, previous research has suggested that the level of suicidal intent appears to be a

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powerful predictor of eventual suicide after attempted suicide (Hjelmeland 1996; Niméus et al. 2002; Suominen et al. 2004). Although a higher level of suicidal in-tent at the time of the suicide attempt has been found to be a risk factor for possible future suicide, it is conceded that a Suicidal Intent Scale cannot forecast which spe-cific patients will die by suicide. Nevertheless, information about suicidal intent is still valuable in clinical suicide-risk assessment (Harriss and Hawton 2005).

Factorial structure of the Pierce Suicidal Intent Scale (PSIS)

In Article III, the PSIS variables were grouped into four factors that described 62.1% of the total variance. Based on ratings for these factors, new scores charac-terising the components of suicidal intent were calculated. These four components were the following: consciously expressed purpose and opinion about potential lethality of the act, termed a Wish to Die; long-term preparations and suicidal communication, termed Arrangements; short-term and immediate preparations, known as Circumstances; and the role played in the current suicide attempt by alco-hol and/or drug consumption, expressed as Alcohol/Drugs (89/138).

Two broadly common factors of suicidal intent, referred to differently in other stud-ies, were expected lethality (described in the present study as the Wish to Die) and planning (Arrangements and Circumstances in the present study). The factor termed Alcohol/Drugs in the present study was distinct from factors in other studies (91/140).

All these components are important indicators in characterising the nuances of the suicidal process before the suicide attempt. The importance of direct and indirect, verbal and nonverbal communication in the development of the suicidal process has been recognised before (Lester 2001; Wasserman 2001b), and these aspects also characterise the level of suicidal intent of suicide attempters in the present study. As stated in a previous study, what patients say should have implications when inter-vention and follow-up are considered (Hjelmeland 1995).

Gender differences in suicidal intent

According to the results of Article III, males and females seem to have similar lev-els of suicidal intent as there were no statistically significant gender differences either in mean total scores for suicidal intent or in scores of single components (90/139). Previous research on suicidal intent has yielded different results: Some have shown higher scores among males (Haw et al. 2003; Harriss et al. 2005) but there are also studies showing higher scores among females (Hamdi et al. 1991) or finding no gender differences (Dyer and Kreitman 1984; Denning et al. 2000; Hjelmeland et al. 2002; Niméus et al. 2002; Hjelmeland and Hawton 2004). In the epidemiology of suicidal behaviour, significant gender differences have been ob-served. In Europe, the average male-to-female suicide ratio is 4:1 and the male-to-female attempted-suicide ratio is 1:1.5 (Schmidtke et al. 2004). There is also a

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study asserting major gender differences in the course of the suicidal process: The median interval from the first suicidal communication to the suicide was found to be shorter in men than in women (Runeson et al. 1996).

Based on these differences, it would be plausible to assume that gender may play an important role in other aspects of suicidal behaviour, such as suicidal intent, as well. It has been argued that male suicide attempts are more likely to be ‘failed’ suicides, while female suicide attempts may more frequently stem from factors other than a desire to commit suicide, such as a wish to communicate distress and the need for help (Hjelmeland et al. 2000). The level of suicidal intent among suicide attempters is relatively easily measurable, but the level of suicidal intent of persons who have committed suicide remains mostly unknown. One study measuring the suicidal intent of people who died by suicide showed no gender differences in scores for suicidal intent, although men chose more violent methods (Denning et al. 2000).

The results of our study corroborated the studies that found no gender differences in suicidal intent (91/140). Evidently, we must accept the fact that, despite epidemiol-ogical gender differences, people who commit suicide and those who make serious suicide attempts form two overlapping populations that are far more alike than dif-ferent (Beautrais 2001).

Age differences in suicidal intent

Analysis by age group in Article III revealed statistically significant differences in mean total scores of suicidal intent and these increased with age. Differences in the mean scores of the following components were statistically significant: Arrange-ments, Circumstances and Alcohol/Drugs. Scores for Arrangements and Circum-stances rose with age. Mean scores for Alcohol/Drugs were highest in the middle age groups (35–44 and 45–54 years) and lowest in the oldest age group (55+). Mean scores for Wish to Die showed no age-group differences (90/139).

Suicidal intent has also been found in some previous studies to be correlated with age, that is, older people have higher scores for suicidal intent (Dyer and Kreitman 1984; Harriss et al. 2005). However, some studies have found that actual intent does not vary greatly with age (Haw et al. 2003; Hjelmeland and Hawton 2004). One surprising finding was the similarity across age groups of the mean score for the Wish to Die component. Scores for this component might be expected to rise with age, since this was true of total scores for suicidal intent. The two components characterising preparations before a suicide attempt (Arrangements and Circum-stances) showed that older people prepared their suicide attempt more carefully and planned it in greater detail (91/140).

Suicidal behaviour, especially with a nonfatal outcome, is frequently a communica-tion act that is not prompted by any real wish to die, termed in the literature a ‘cry for help’ (Farberow and Shneidman 1961). Analysis of the age variable in the cur-rent research showed that suicide attempts are often of a communicative nature,

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among younger people in particular: Their arrangements for a fatal outcome were less well prepared and the circumstances in which the suicidal acts were committed were chosen to make interruption more probable (91/140).

Another component of suicidal intent that was not found to increase with age was Alcohol/Drugs. The role of alcohol or drugs in facilitating suicide attempts was largest among the middle-age groups. According to Kõlves et al (2006), among suicide victims in Estonia, middle-aged men are the highest risk group for alcohol abuse and dependence. It must be borne in mind that, in the present study, the com-ponent Alcohol/Drugs does not differentiate between alcohol abusers and non-abusers, and the results should, therefore, be interpreted with care (91-92/140-141). It is known from a previous study that alcohol-dependent suicide attempters obtain relatively low scores on the Suicidal Intent Scale. Although these patients may lack a strong wish to die, they are, nonetheless, at high risk for making fatal suicide at-tempts (Nielsen et al. 1993).

Self-rated suicidal intent with respect to external characteristics

To characterise the severity of attempted suicide separately from self-rated suicidal intent, the following variables were chosen for analysis in Article III: psychiatric disorders and method of attempting suicide (both coded according to the ICD-10), duration of hospitalization after the suicide attempt and interviewers’ assessment regarding the physical consequences of and danger to life entailed by the suicide attempt.

Suicide attempters with serious psychiatric diagnoses (affective disorders or schizo-phrenia) had significantly higher mean scores for suicidal intent, while those with an acute stress reaction or other diagnosis, or who had no diagnosis, had a lower level of suicidal intent. Psychiatric disorders have been clearly linked to suicidal behaviour (Joiner et al. 2005) and the results of the present study did, indeed, con-firm the role of psychiatric disorders in the suicidal process.

Mean scores for suicidal intent were highest among suicide attempters who used poisoning as their method of attempting suicide, followed by those who used other (hard) methods and self-harm by sharp objects (90/139). The apparent physical danger of the method of attempting suicide chosen (an overdose) has been found to be a poor and potentially misleading measure of how much a patient may have wanted to die (Hawton 2000). This was corroborated by the present study (92/141). Although poisoning has been classified as a ‘soft’ suicide method compared with other methods (Spicer and Miller 2000), the suicidal-intent level of suicide attempt-ers using poisoning has been shown to be higher than that of others. Suicide at-tempters are probably incapable of adequately assessing the potential lethality of the drugs or substances they ingest. The lowest level of suicidal intent was found among suicide attempters who used sharp objects for self-harm. These persons are most likely to be ‘habitual self-harmers’, who behave in self-destructive ways with-out being highly suicidal (Skegg 2005).

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Those who stayed in hospital for three days after the suicide attempt had higher mean scores for suicidal intent than those whose hospital stays were shorter or longer (90/139). Three days is probably the period needed for stabilization of the suicide attempter’s condition. It is very likely that persons committing less severe suicide attempts spend up to two days in hospital, but no more. Suicide attempters who stay in hospital for long periods probably suffer from complications they did not initially mean to provoke and this may explain their lower level of suicidal in-tent. All in all, conclusions about the severity of attempted suicide based on the duration of hospitalization should be drawn carefully since, in every single case, the physical consequences are not only the outcome of the current suicide attempt, but also depend on broader background factors, such as the general health and fitness of the suicide attempter and the availability and effectiveness of healthcare services (92/141).

One finding of our study was that interviewers did not succeed in differentiating among suicide attempters according to their level of suicidal intent while assessing physical consequences, need for medical attention/treatment, and danger to life of the suicide attempt (90,92/139,141). Nevertheless, this does not disparage the inter-viewers’ entire contribution, since there are indications that any question in a Suici-dal Intent Scale can assess a suicidal person’s real intention more precisely than a clinician’s objectively observed assessment of the potential lethality of the suicide attempt (Watson et al. 2001).

Associations with well-being, depression and hopelessness

The results of Article II revealed that suicidal intent was negatively correlated with well-being and positively with depression and hopelessness. Lower well-being and higher depression or hopelessness indicated more severe suicidal intent. Suicidal intent correlated most strongly with well-being. Well-being was correlated nega-tively with impaired emotional status, as assessed by all other scales: the lower the well-being, the higher the score of depression and hopelessness. The correlation was the strongest with depression. Multiple-item and one-item hopelessness scales had similar correlations with other scales, with only minor variations in magnitude of the correlation coefficient. Correlations between different scales were also sig-nificant in the analysis by gender and age group, with two exceptions only: the correlation between suicidal intent and hopelessness (both multiple-item and one-item scales) did not reach significance in males or in older adults (40 or more years old) (81/433).

The finding regarding depression and hopelessness was expected: The severity of the suicide attempt correlated with the level of depression and hopelessness. There are indicators that 60-70% of patients with acute depression experience suicidal ideas and 10-15% of depressive patients commit suicide (Möller 2003). Depression is the psychiatric diagnosis most strongly linked with suicide (Wasserman 2001a). Hopelessness has been defined as ‘the system of cognitive functions with the com-

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mon denominator of negative expectations for the future’ (Beck et al. 1974b). Hopelessness does not necessarily mean only the presence of negative thoughts but it is even more strongly correlated with lack of positive thoughts about the future (MacLeod et al. 2005). Hopelessness is highly associated with depression and sui-cidal behaviour (Beck et al. 1993; Kuo et al. 2004) and has been considered a key variable linking depression to suicidal behaviour (Beck et al. 1975; Dyer and Kreitman 1984). An interesting practical finding of the current study was that the multiple-item and one-item hopelessness scales had similar results, which confirms previous suggestions that, in order to be less stressful for interviewees to answer, the hopelessness scale can be shortened without losing important information (Aish and Wasserman 2001; Yip and Cheung 2006) (81/433).

Well-being measured by the WHO well-being index (WHO-5) turned out to be an important issue, along with the already well-known characteristics and risk factors of suicide attempt such as depression and hopelessness. The correlations between the WHO-5 and other scales were all at a significant level. The strong side of the WHO-5 is its shortness and positive questions, which are not too difficult to answer (Henkel et al. 2004a). It has been argued that psychometric scales to be used in a daily clinical setting should be simple and brief (Bech et al. 2001). The questions of the WHO-5, geared towards measuring cheerfulness and the level of energy, work in the screening of depression as successfully as questions narrowly oriented to-wards depressive symptoms, which could be hidden by patients because of the shame and stigma associated with mental disorders (Henkel et al. 2004a) (82/434).

It is also known that the WHO-5 also gives many false-positive results – people with a low score of well-being do not necessarily suffer from clinical depression (Henkel et al. 2003; Henkel et al. 2004b). General statements such as those in-cluded in the WHO-5 improve sensitivity and the negative predictive value of the scale at the cost of specificity and positive predictive value (Primack 2003). There-fore, the low level of well-being screened by the WHO-5 should lead a specialist in clinical work to investigate the severity of depression and hopelessness further, as these are associated with suicidal behaviour (82/434).

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CONCLUSIONS

The current study focused on attempted suicide as a social phenomenon and re-vealed the relevance of the sociological as well as epidemiological, medical and psychological aspects of attempted suicides. The current dissertation explained how both the formal social structures and subjective meanings individuals give to their behaviours and beliefs are important in understanding the phenomenon of attempted suicide in societies of differing sociocultural backgrounds.

Article I showed how suicide attempters were identified in everyday interactions in emergency departments in general hospitals and highlighted that accurate, standard-ized information on the rates and characteristics of medically treated suicide at-tempts is essential in the development and evaluation of preventative services. However, emergency departments of hospitals in both developed and less-developed countries are not currently able to collect this information routinely. The article pointed out several of the difficulties that need to be overcome to rectify this problem: Incomplete or inaccurate registration of persons seen in emergency de-partments; patients and family members intentionally misreporting the cause of the attempted suicide injury or absconding from the emergency department as soon as possible to avoid stigma and (in some cases) legal sanctions; clinicians routinely not recording suicide attempts as such and, therefore, failing to collect essential infor-mation or to provide follow-up referrals (in some cases because they wish to avoid legal proceedings). The magnitude and causes of the problems vary across the coun-tries included in this study, largely due to cultural and socioeconomic factors. Recti-fying these problems will require substantial legal, administrative and attitudinal changes.

According to the results of Article IV, individual-level associations between differ-ent dimensions of religiosity – religious denomination, organisational denomina-tion, and subjective religiosity – and attempting suicide exist. Nevertheless, these associations varied between dimensions of religiosity and across cultures. In par-ticular, subjective religiosity (considering oneself to be a religious person) may serve as a protective factor against non-fatal suicidal behaviour in some cultures. Structural and formal religious dimensions seem to be less relevant.

In the Pierce Suicidal Intent Scale (PSIS) as described in Article III, four compo-nents characterising the nuances of the suicidal process before attempted suicide were very clearly differentiated. The level of suicidal intent was not gender-dependent but did increase with age. Males and females were also similar with re-spect to the individual components of suicidal intent. Although scores for the un-equivocally expressed Wish to Die component were similar among all age groups, scores for more equivocal communication components (termed Arrangements and Circumstances) increased with age. The Alcohol/Drugs component had higher scores among the middle age groups. Level of suicidal intent was associated with psychiatric diagnosis, method of attempting suicide and duration of hospitalization after suicide attempt. In the interviewers’ assessment, there were no differences in

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the level of suicidal intent among groups of suicide attempters categorised in terms of the physical consequences and danger to life owing to the suicide attempt. The level of suicidal intent as measured by a self-rated scale expresses the subjective meaning an individual gives to his or her act. It is valuable information on the sui-cidal person’s true intention and could help clinical observation performed by a specialist in suicide risk assessment.

Article II demonstrated that, in understanding the severity of attempted suicide, self-rated scales measuring emotional status could serve as useful instruments. A low level of subjective psychological well-being is associated with a high level of suicidal intent, depression and hopelessness in suicide attempters. Subjective psy-chological well-being has high relevance in the assessment of the severity of at-tempted suicide. Short and positively loaded scales measuring protective factors, such as the WHO-5, should be preferred for preliminary suicide risk assessment, especially in settings without psychological/psychiatric expertise. However, the WHO-5 is a screening instrument to select vulnerable subjects and further specific suicide risk assessment is mandatory.

The study left open at least two main directions for future research. First, in addi-tion to the current research questions, it would be interesting to study the interaction effects of the three pillars – religiosity, subjective well-being and suicidal intent – in predicting attempted suicide. The main effect does not always necessarily reflect the interplay between these factors in the specific social context. Second, further research to create a better understanding about the social construction of attempted suicide and the subjective meanings suicide attempters attach to their acts needs a qualitative approach with narrative interviews as the quantitative data available for the current study do not allow deeper insight into the phenomenon.

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KOKKUVÕTE

Suitsiidikatse sotsiaalne konstruktsioon ja subjektiivne tähendus Suitsidaalne käitumine on keerukas bio-psühho-sotsiaalne nähtus ja selle erinevate aspektide uurimine on samaväärselt tähtis (Wasserman and Wasserman 2009). Suitsidaalse käitumise uuringute traditsioon sotsioloogilises võtmes on alguse saa-nud Durkheimi klassikalisest teooriast (1897/2002). Durkheimi käsitluse kohaselt on suitsiid kollektiivne sotsiaalne nähtus: sotsiaalne fakt, mis on üksikisiku suhtes väline reaalsus ning mida ei saa seletada üksikisiku tasandi riskiteguritega. Enamik hilisematest suitsidaalse käitumise sotsioloogilistest käsitlustest on kas Durkheimi strukturaalse teooria kriitika või selle edasiarendus.

Käesolev dissertatsioon on kirjutatud teoreetilises raamistikus, milles kasutatakse selliseid kontseptsioone nagu post-materiaalsed väärtused, kultuur ja subjektiivne heaolu (Inglehart 1997); aktiivne mina (Giddens 1991/2004); käitumise subjektiiv-ne tähendus (Weber et al. 1921/1978; Douglas 1967}; igapäevaelu reaalsuse konst-rueerimine interaktsioonide käigus (Berger and Luckmann 1966/1991; Spector and Kitsuse 1987; Searle 1995). Nende teooriate ühine tunnusjoon on fenomenoloogili-ne lähenemisviis, mis asetab üksikisiku aktiivse osalejana sotsiaalse reaalsuse keskmesse, mis väidab, et sotsiaalne reaalsus luuakse interaktsioonide käigus, ning tähtsustab üksikisiku poolt oma käitumisele antavat subjektiivset tähendust.

Sotsioloogilised suitsidaalse käitumise uuringud on keskendunud peamiselt lõpule-viidud suitsiidile ja vähem on teada suitsiidikatsest kui sotsiaalsest nähtusest. Lisaks on enamik suitsiidikatsete uuringuid viidud läbi arenenud maades ning vähem on teada madala ja keskmise sissetulekuga maade kohta, eriti ülemaailmses võrdlevas perspektiivis. Käesoleva dissertatsiooni eesmärk on analüüsida suitsiidikatset kui sotsiaalset nähtust ning on rajatud eeldusele, et kõrvuti epidemioloogiliste, medit-siiniliste ja psühholoogiliste aspektidega omavad suitsiidikatse kui nähtuse seleta-misel olulist tähtsust ka sotsioloogilised aspektid.

Empiiriline materjal dissertatsiooni jaoks koguti WHO SUPRE-MISS uuringu käi-gus, mille eesmärgiks oli suurendada teadmist suitsidaalse käitumise kohta kultuuri-liselt erinevates paikades üle maailma. Osalevad keskused olid valitud Maailma Terviseorganisatsiooni (WHO) ekspertgrupi poolt keskmise ja madala sissetulekuga maadest, kus suitsiidikatsete kohta on vähem uurimistöid läbi viidud: Campinas (Brasiilia), Chennai (India), Colombo (Sri Lanka), Durban (Lõuna-Aafrika Vaba-riik), Hanoi (Vietnam), Karaj (Iraan), Tallinn (Eesti) and Yuncheng (Hiina). And-mete kogumine toimus aastatel 2002 kuni 2004. Struktureeritud näost-näkku interv-juud viidi läbi meditsiinilist abi saanud suitsiidikatse sooritanutega (n = 4314) ja kontrollgrupiga (n = 5484). Koostati kvalitatiivsed kirjeldused suitsidaalse käitumi-se sotsiaalkultuurilise tausta kohta.

Käesolev dissertatsioon koosneb neljast artiklist, mis põhinevad samal empiirilisel materjalil ja käsitlevad suitsiidikatse temaatikat pisut erinevatest vaatenurkadest. Teoreetiline raamistik loob artiklite vahele silla ja ühendab need sotsioloogilises

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võtmes. Lisaks on dissertatsiooni tulemuste ja diskussiooni esimeses osas antud seni veel avaldamata materjalil baseeruv WHO SUPRE-MISS uuringus osalevate kes-kuste kvalitatiivne kirjeldus suitsidaalset käitumist mõjutava sotsiaalkultuurilise tausta kohta. Kirjeldused hõlmavad religioosseid struktuure, surmaga seotud rituaa-le ja tseremooniaid ning hoiakuid suitsidaalse käitumise suhtes.

Artiklis I on kirjeldatud suitsiidikatse sooritanute peamisi iseloomulikke tunnuseid ning suitsiidikatsete käsitlemise rutiine erinevates keskustes. Kõigis keskustes oli suitsiidikatse sooritanute hulgas rohkem naisi kui mehi (Tallinnas naisi 66%) ning suitsiidikatse sooritanud olid pigem noored (Tallinnas vanuse mediaan naistel 30 ja meestel 29). Peamine suitsiidikatse meetod oli kõigis keskustes mürgistus (66-98%) ning Tallinna iseloomustavaks tunnuseks oli muu meetodi kombineerimine alkoholi tarvitamisega. Väga vähesed suitsiidikatse sooritanutest (0-34%) suunati suitsiidi-katse järgselt edasi psühhiaatrilise abi saamiseks.

Uuringu tulemused näitasid, kuidas suitsiidikatse sooritanud isikud üldhaiglate erakorralise meditsiini osakondades igapäevaste interaktsioonide käigus identifit-seeriti. Arvestades vajadust töötada välja ja hinnata efektiivseid ennetustegevusi, on väga oluline omada täpset ja standardiseeritud teavet meditsiinilist abi saanud suit-siidikatse sooritanute arvu ja neid iseloomustavate tunnuste kohta. Kahjuks ei kogu-ta selliseid andmeid rutiinselt peaaegu mitte kusagil maailmas. Probleemid andmete kogumisega olid WHO SUPRE-MISS uuringusse kaasatud maades erinevad, seda paljuski kultuurilistest ja sotsiaal-majanduslikest põhjustest tulenevalt: ebatäielik ja ebatäpne erakorralise meditsiini osakonda pöördunud või toodud suitsiidikatse soo-ritanute registreerimine; vigastuse või mürgistuse tegeliku põhjuse tahtlik varjamine patsientide ja nende pereliikmete poolt; erakorralise meditsiini osakonnast lahkumi-ne esimesel võimalusel pärast esmaabi saamist selleks, et vältida stigmat ehk häbi-märgistatust ja mõnedes maades ka juriidilisi sanktsioone; meditsiinitöötajate pool-ne tähelepanematus vigastuse või mürgistuse tekitamise tahtluse osas ning sellest tulenevalt suitsiidikatse sooritanute puudulik edasisuunamine psühhiaatrilise abi saamiseks (mõningatel juhtudel ka selleks, et vältida juriidilist menetlust). Nende probleemide parandamine eeldab olulisi muudatusi juriidilistes ja administratiivse-tes protseduurides ning hoiakutes.

Artiklis IV uuriti võrdlevas perspektiivis, kas religioossus mõõdetuna kolmes erine-vas dimensioonis – religioosne denominatsioon, organisatsiooniline religioossus ja subjektiivne religioossus – on suitsiidikatse vastu kaitsvaks teguriks. Uuringu tule-muste kohaselt on indiviidi-tasandi seosed religioossuse erinevate dimensioonide ja suitsiidikatse sooritamise vahel olemas. Need seosed on religioossuse eri dimen-sioonide ja erinevate kultuuride puhul erinevad. Eriti subjektiivne religioossus võib mõnedes kultuurides toimida mitte-fataalse suitsidaalse käitumise vastu kaitsva tegurina. Strukturaalsed ja formaalsed religioossuse dimensioonid (religioosne denominatsioon, organisatsiooniline religioossus) näivad olevat vähem olulised.

Artiklid II ja III põhinevad ainult Eesti andmetel ja puudutavad subjektiivset tähen-dust, mille respondendid annavad oma suitsiidikatsele. Artiklis III iseloomustati suitsiidikatse raskusastet suitsiidikavatsuse skaalal eristuvate faktortunnuste skoori-

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de põhjal ning analüüsiti suitsiidikavatsuse taset soo ja vanuse lõikes ning lähtudes väliselt hinnatavatest tunnustest. Suitsiidikavatsuse skaalal eristusid selgelt neli faktorit, mis iseloomustavad suitsiidikatsele eelnevat suitsiidiprotsessi: tegelik sur-masoov, pikemaajalised ettevalmistused, vahetud asjaolud ning seos alkoho-li/narkootikumidega. Meeste ja naiste vahel faktorite skoorides erinevusi polnud. Tegeliku otsese surmasoovi skooris ei olnud vanuselisi erinevusi, kuid kaudset kommunikatsiooni väljendavate faktorite skoorid (pikemaajalised ettevalmistused ja vahetud asjaolud) suurenesid vanusega. Seos alkoholi/narkootikumidega oli kõr-geima skooriga keskealiste hulgas. Ilmnesid seosed suitsiidikavatsuse raskusastme ning psühhiaatrilise diagnoosi, kasutatud suitsiidikatse meetodi ning hospitaliseeri-mise kestuse vahel. Suitsiidikatse raskusaste hinnatuna enesehinnangulise suitsiidi-kavatsuse skooriga ning intervjueerijate kui välisvaatlejate poolt antud hinnang suitsiidikatse eluohtlikkusele ei langenud kokku. Seega on subjektiivne tähendus, mille suitsiidikatse sooritaja oma suitsidaalsele aktile annab, väga oluline informat-sioon lisaks välisele hindamisele, mida teostatakse spetsialisti poolt suitsiidiriski hindamise käigus.

Artiklis II analüüsiti seoseid suitsiidikavatsuse skaala abil mõõdetud suitsiidikatse raskusastme ning suitsiidikatse sooritanu emotsionaalset seisundit iseloomustavate tunnuste vahel. Emotsionaalset seisundit hinnati depressiooni, lootusetuse ja subjek-tiivse heaolu skaalade abil. Ilmnes, et madal subjektiivne psühholoogiline heaolu on seotud kõrge suitsiidikavatsuse, depressiooni ja lootusetuse tasemega. Subjektiivne psühholoogiline heaolu mõõdetuna WHO-5 skaalal on oluline post-materiaalne väärtus, millel on suur tähtsus suitsiidikatse raskusastme hindamise seisukohalt. Niisugune lühike ja positiivse alatooniga kaitsvaid tegureid mõõtev skaala võiks olla eelistatud esmasel suitsiidiriski hindamisel, eriti asutustes, kus puudub psühho-loogiline/psühhiaatriline kompetents. Siiski tuleb meeles pidada, et WHO-5 selek-teerib küll usaldusväärselt välja haavatavad indiviidid, kuid edasine põhjalikum suitsiidiriski hindamine on kindlasti vajalik.

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65 49

PUBLICATIONS

Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Botega, N., Phillips, M., Sisask, M., Vjayakumar, L., Malakouti, K., Schlebusch, L., De Silva, D., Nguyen, V. T. and Wasserman D. (2005). Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries. Psychological Medicine, 35(10): 1467-1474.

69

Characteristics of attempted suicides seen inemergency-care settings of general hospitals in eight

low- and middle-income countries

ALEXANDRA FLEISCHMANN 1, JOSE M. BERTOLOTE 1*, DIEGO DE LEO 2,NEURY BOTEGA 3, MICHAEL PHILLIPS 4, MERIKE SISASK 5,

LAKSHMI VIJAYAKUMAR 6, KAZEM MALAKOUTI 7, LOURENS SCHLEBUSCH 8,DAMANI DE SILVA 9, VAN TUONG NGUYEN 1 0

AND DANUTA WASSERMAN 1 1

1 Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland ;2 Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Queensland, Australia ;3 Department of Psychiatry, FCM – UNICAMP, Campinas, Brazil ; 4 Beijing Suicide Research and Prevention

Center, Beijing Hui Long Guan Hospital, Beijing, People’s Republic of China ; 5 Estonian-Swedish MentalHealth and Suicidology Institute, Estonian Center of Behavioral and Health Sciences, Tallinn, Estonia ;

6 Department of Psychiatry, Voluntary Health Services & SNEHA, Kotturpuram, Chennai, India ;7 Tehran Psychiatric Institute, Mental Health Research Centre, Tehran, Islamic Republic of Iran ;

8 Department of Behavioural Medicine, School of Family and Public Health Medicine, Faculty of HealthSciences, Nelson R. Mandela School of Medicine, University of KwaZulu–Natal, Durban, South Africa ;

9 Department of Psychological Medicine, Faculty of Medicine, University of Colombo, Sri Lanka ;10 Hanoi Medical University, Hanoi, Viet Nam ; 11 National and Stockholm County Centre for Suicide Research

and Prevention of Mental Ill-Health (NASP), Department of Public Health Sciences, Karolinska Instituteand Swedish National Institute of Psychosocial Medicine, Stockholm, Sweden

ABSTRACT

Background. The objective was to describe patients presenting themselves at emergency-caresettings following a suicide attempt in eight culturally different sites [Campinas (Brazil), Chennai(India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Viet Nam), Karaj (Iran), Tallinn(Estonia), and Yuncheng, (China)].

Method. Subjects seen for suicide attempts, as identified by the medical staff in the emergencyunits of 18 collaborating hospitals were asked to participate in a 45-minute structured interviewadministered by trained health personnel after the patient was medically stable.

Results. Self-poisoning was the main method of attempting suicide in all eight sites. Self-poisoningby pesticides played a particularly important role in Yuncheng (71.6% females, 61.5% males), inColombo (43.2% males, 19.6% females), and in Chennai (33.8% males, 23.8% females). Thesuicide attempt resulted in danger to life in the majority of patients in Yuncheng and in Chennai(over 65%). In four of the eight sites less than one-third of subjects received any type of referral forfollow-up evaluation or care.

Conclusions. Action for the prevention of suicide attempts can be started immediately in thesites investigated by addressing the one most important method of attempted suicide, namely self-poisoning. Regulations for the access to drugs, medicaments, pesticides, and other toxic substancesneed to be improved and revised regulations must be implemented by integrating the effortsof different sectors, such as health, agriculture, education, and justice. The care of patients whoattempt suicide needs to include routine psychiatric and psychosocial assessment and systematicreferral to professional services after discharge.

* Address for correspondence: Dr Jose M. Bertolote, Department of Mental Health and Substance Abuse, World Health Organization,CH-1211, Geneva 27, Switzerland.(Email : [email protected])

Psychological Medicine, 2005, 35, 1467–1474. f 2005 Cambridge University Pressdoi:10.1017/S0033291705005416 Printed in the United Kingdom

1467

70

INTRODUCTION

Suicide is not only a global and personaltragedy, but also a major public health problem.In 2002, it was estimated that 877 000 lives werelost due to suicide (WHO, 2003). Suicide occursin both developed and developing countries, inall age groups. For the past few decades theglobal picture has been one of rising trends,particularly among younger age groups, wheresuicide is among the five leading causes of deathfor both sexes.

Depending on the location, suicide attemptscan be up to 10–40 times more frequent thancompleted suicides (Schmidtke et al. 1996). Inmany countries, suicide attempts are one of themain reasons for hospital emergency treatmentof young people, putting a heavy burden onhealth-care systems. The majority of individualswho attempt suicide tend to be adolescentsand young adults, and together they form apool from which many future suicides emerge(United Nations Department for Policy Co-ordination and Sustainable Development, 1996;Hulten et al. 2000).

Whereas many WHO Member States reporton mortality, including suicide mortality, noofficial or systematically collected statistics onsuicide attempts exist on a national basis. TheWHO/EURO multicentre study on suicidal be-haviour, monitored attempted suicides treatedat 25 health facilities in 19 European countries,including Israel and Turkey (Platt et al. 1992;Schmidtke et al. 2004) between 1989 and 1992.However, the information thus obtained cannotbe construed as representing the respective‘national reality ’.

In 2000, the WHO launched the multisiteintervention study on suicidal behaviours(SUPRE-MISS) which aimed to increase knowl-edge about suicidal behaviours and about theeffectiveness of interventions for suicide at-tempters in culturally diverse places around theworld.

SUPRE-MISS has three components: (i)a randomized clinical trial to evaluate treat-ment strategies for suicide attempters re-suscitated in emergency settings in definedcatchment areas ; (ii) a community survey toidentify suicidal ideation and behaviour inthe same catchment areas; and (iii) a quali-tative community description of the basic

socio-cultural characteristics of the target com-munities.

This paper describes the characteristics ofthe suicide attempters of the intake component(i). The majority of these participated in therandomized clinical controlled trial.

METHOD

The emergency-care departments

The study was carried out in one or moreemergency-care departments of the partici-pating sites. In Campinas (Brazil), it wasHospital das Clinicas, Universidade Estadual deCampinas. In Chennai (India), the GovernmentRoyapettah Hospital. In Colombo (Sri Lanka),the acute care wards of the National HospitalSri Lanka. In Durban (South Africa), theAddington, King Edward VIII, RK Khan,and Prince Mshiyeni Memorial hospitals wereinvolved in the study. In Hanoi (Viet Nam), theBach Mai, Dong Da, Saint Pault, and ThanhNhan hospitals participated. In Karaj (TheIslamic Republic of Iran), the Emam, Madani,Ghaem and Rajaee hospitals were involved. InTallinn (Estonia), the North Estonian RegionalHospital (the Tallinn Mustamae Hospital andthe Tallinn Psychiatric Clinic) participated. InYuncheng (People’s Republic of China), it wasthe Yuncheng County Hospital. These hospitalsserved the respective catchment area of theparticipating sites which were mostly urban,except for Yuncheng which was rural.

Subjects

All suicide attempters identified betweenJanuary 2002 and January 2004 (in Hanoi upto April 2004) in emergency-care settings bymedical staff within a catchment area with apopulation of at least 250 000 in eight countrieswere invited to participate in the study. Thosewho agreed, filled in a consent form and wereadministered the detailed intake interview.A total of 4314 subjects were included. Theirdistribution by age, sex and site is given inTable 1.

Interviewing

At each site 2–12 psychiatrists, medical doctors,psychologists and, in one instance, psychiatricnurses were trained to administer the intake

1468 A. Fleischmann et al.

71

interview. The interviews were conducted face-to-face and took place at the emergency-caredepartments. Suicide attempters were identifiedby the medical staff in the emergency roomsand interviewed once medically stable, at most3 days after the emergency room admission.

Instrument

The questionnaire, based on the EuropeanParasuicide Study Interview Schedule (EPSIS),(Kerkhof et al. 1999), of the WHO/EUROmulticentre study on suicidal behaviour wastranslated and pilot-tested in each country. Itcovered a detailed intake part comprisingthe method of the suicide attempt, physicalconsequences, the type of care and referral asdetermined by the medical staff, as well as socio-demographic information. A series of othervariables was also answered, the results of whichare not reported here (WHO, 2002a).

RESULTS

The intake of subjects

An attempt was made to include all suicideattempters seen at the emergency-care de-partments. However, inadequate recording ofemergency room visits, intentional misreportingof suicides as accidental by patients and familymembers, failure of the emergency room staffto notify research staff, and rapid departurefrom the emergency rooms of patients (beforethe research staff could arrive) made it difficultto include all eligible patients in the intake, toenrol them eventually and, in some instances,even to make an accurate assessment of thetotal number of suicide attempters coming tothe emergency-care units. Given the nature ofthese reasons, it is impossible to both estimatethe number of these ‘ losses’ and identify meansof avoiding them.

In Karaj (n=945) and Hanoi (n=301) allsuicide attempters identified in the emergency-care departments over the specified periodparticipated in the intake evaluation. In Cam-pinas (n=162), Durban (n=570) and Colombo(n=1067) almost all subjects completed theintake interview. However, the total number ofsuicide attempters seen at the emergency-caredepartment was not known, because it wassuspected that a small (unknown) number ofcases was not notified by the emergencydepartments to the researchers : the subjectscould have been admitted directly to a psy-chiatric unit without being treated in theemergency department or the subjects mighthave left before the research team could meetthem. Also, in Colombo almost all self-poisoning and surgically serious self-injurypatients who were admitted participated in theintake evaluation, but the number of suicideattempts that were not seen at the acute carewards was unknown.

In Chennai 680 out of 1691 (40%), in Tallinn469 out of 884 (53%) and in Yuncheng 120out of 194 (62%) suicide attempters seen in theemergency-care departments participated inthe intake interview. Of those who did notparticipate, only sex and age are known; themajority of those not interviewed precipitouslyleft the emergency-care department before theresearchers arrived to conduct the interview.

Sociodemographic characteristics

In all sites, more female than male suicideattempters presented themselves at the emerg-ency-care departments ranging from 51.3%(Chennai) to 71.2% (Durban). Three persons(one in Campinas, two in Durban) indicatedthemselves to be transsexual. Overall, thepatients were young. The median age amongfemales ranged from 21 years (Durban) to 30

Table 1. Sex and age of suicide attempters at emergency care departments of SUPRE-MISS sites

Campinas Chennai Colombo Durban Hanoi Karaj Tallinn Yuncheng(n=162) (n=680) (n=1067) (n=570) (n=301) (n=945) (n=469) (n=120)

M F M F M F M F M F M F M F M F

Sex (%, rounded) 35 64 49 51 44 56 27 71 29 71 42 58 34 66 33 68Age (years) (median) 29 30 25 22 25 22 26 21 24 23 23 22 29 30 33 30

M, Male; F, female.

Suicide attempts in developing countries’ emergency care 1469

72

years (Campinas and Yuncheng) and from 23(Karaj) to 33 years (Yuncheng) among males.Campinas and Tallinn were the only sites wherethe median age of females was higher than formales (Table 1).

In six of the eight countries male attempterswere more likely to be single than married, andin four of the eight countries female attempterswere more likely to be single than married. In allsites, except for Campinas, female attempterswere more likely to be married than maleattempters (Table 2). Divorce was commonamong suicide attempters in Campinas (17.5%males, 22.3% females) and in Tallinn (13.0%males, 14.6% females). In all sites, except forCampinas, women were more frequentlymarried than men (Table 2).

With the exception of Yuncheng (wheremen had a higher educational attainment thanwomen) the educational achievement of maleand female suicide attempters was similar(Table 2).

Except for Durban and Karaj the majorityof subjects were employed full-time or part-timeat the time of admission to the emergency-caredepartments. The other common employmentcategories were ‘unemployed’, ‘housekeeper’and ‘full-time student’ (Table 2).

Main method of the suicide attempt accordingto ICD-10 codes

Self-poisoning – which accounted for 69–98%of all cases – was the predominant method ofsuicide attempts seen in the emergency depart-ments at all sites, far exceeding the othermethods of ‘cutting’, ‘hanging’, etc. (Table 3).In most cases self-poisoning involved theingestion of pesticides or medications. InYuncheng pesticide ingestion was the mostfrequently reported method among both men(61.5%) and women (71.6%); in Colombo andChennai it was the most commonly usedmethod in men (43.2% and 33.8% respectively)and the second most commonly used method inwomen (19.6% and 23.8% respectively) ; it wasalso an important method in Campinas andHanoi.

More than one method, i.e. a combination ofmethods, was rarely applied. The one exceptionwas in Tallinn, where 10.7% of the suicideattempters combined self-poisoning by alcoholwith another method.T

able2.

Socio-dem

ographiccharacteristics

ofsuicideattem

pters

seen

atem

ergency-care

hospitalsin

SUPRE-M

ISSsites(%

rounded)

Campinas

Chennai

Colombo

Durban

Hanoi

Karaj

Tallinn

Yuncheng

MF

MF

MF

MF

MF

MF

MF

MF

Maritalstatus

(n=

57)

(n=103)

(n=

331)

(n=

349)

(n=465)

(n=589)

(n=155)

(n=400)

(n=87)

(n=211)

(n=395)

(n=548)

(n=

161)

(n=

308)

(n=39)

(n=

81)

Single

28

35

50

40

59

57

68

68

70

59

67

41

47

33

23

16

Married

51

41

47

54

38

42

19

24

28

39

31

56

39

46

69

82

Separateda

21

24

36

22

13

82

22

314

21

82

Education

(n=

57)

(n=104)

(n=

330)

(n=

349)

(n=438)

(n=569)

(n=152)

(n=401)

(n=53)

(n=167)

(n=396)

(n=549)

(n=

161)

(n=

308)

(n=39)

(n=

81)

None

11

14

919

44

32

01

24

45

15

28

Primary

47

39

28

24

15

938

29

41

13

10

24

24

31

47

Secondary

25

20

48

43

79

83

51

61

21

15

33

23

32

33

49

24

Higher

14

26

16

14

14

77

64

61

53

63

38

36

51

Other

41

00

00

12

11

22

00

22

00

Employment

(n=

52)

(n=

90)

(n=

323)

(n=

308)

(n=446)

(n=551)

(n=142)

(n=370)

(n=64)

(n=170)

(n=393)

(n=548)

(n=

161)

(n=

308)

(n=39)

(n=

81)

Full/part-tim

e58

33

79

50

67

38

40

25

38

32

23

454

51

85

83

Unem

ployed

25

23

10

412

11

29

29

14

926

118

12

31

Student

08

67

918

18

34

27

29

13

20

817

83

Housekeeper

012

035

026

17

28

268

04

04

Other

b10

16

20

12

38

48

734

719

14

37

M,Male;F,female.

aSeparated/divorced

orwidowed.

bOther

includes

sick

leave/disabled,temporary

work,arm

edforce,retired.


73

Table3.

Main

methodofattem

ptedsuicideaccordingto

ICD-10codes

inSUPRE-M

ISSsites(%

rounded)

Campinas

Chennai

Colombo

Durban

Hanoi

Karaj

Tallinn

Yuncheng

MF

MF

MF

MF

MF

MF

MF

MF

(n=56)

(n=104)

(n=

331)

(n=349)

(n=

465)

(n=586)

(n=

153)

(n=395)

(n=

83)

(n=205)

(n=395)

(n=546)

(n=161)

(n=308)

(n=39)

(n=81)

Self-poisoning

Non-opioid

analgesics

andantipyretics

02

15

14

27

48

54

52

75

913

11

22

00

Anti-epilepticand

sedative-hypnoticdrugs

39

58

812

811

10

64

10

51

47

50

59

31

21

Other

medicaments

26

33

40

816

917

22

11

13

32

03

Alcohol

02

00

10

00

00

11

21

00

Pesticides

18

734

24

43

20

23

16

53

21

062

72

Other

a13

521

17

17

19

17

16

16

516

21

43

52

AllPoisonings

72

79

97

98

91

93

86

96

89

98

91

96

69

88

97

98

Hangingandsuffocation

26

31

21

52

72

10

75

33

Cuttingwithsharp

or

bluntobject

18

40

02

14

22

06

220

60

0

Other

b9

12

01

66

61

11

32

42

00

M,Male;F,female.

aSelf-poisoningother,including:narcotics

andpsychodysleptics,notelsewhereclassified

;other

drugsactingontheautonomic

nervoussystem

;organic

solvents

andhalogenatedhydro-

carbonsandtheirvapours;other

gasesandvapours;other

andunspecified

chem

icalsandnoxioussubstances.

bOther,includingdrowning;allfirearm

s;sm

oke,fire,steam

andhotobjects;jumpingfrom

ahighplace;jumpingorlyingbefore

amovingobject;other

specified

means;unspecified

means.

Table4.

Consequencesoftheattem

ptedsuicideandcare

intheSUPRE-M

ISSsites(%

rounded)

Campinas

Chennai

Colombo

Durban

Hanoi

Karaj

Tallinn

Yuncheng

MF

MF

MF

MF

MF

MF

MF

MF

Physical

consequences

(n=57)

(n=

102)

(n=331)

(n=349)

(n=472)

(n=587)

(n=153)

(n=402)

(n=88)

(n=213)

(n=396)

(n=549)

(n=160)

(n=308)

(n=39)

(n=

81)

None

18

28

00

16

20

20

18

68

11

12

33

00

Mix

a30

35

25

34

47

52

77

76

65

81

74

77

53

59

33

20

Yes

b53

37

75

66

37

28

46

30

11

15

11

44

37

67

80

Referral

(n=28)

(n=43)

(n=331)

(n=346)

(n=424)

(n=560)

(n=133)

(n=357)

(n=88)

(n=213)

(n=392)

(n=553)

(n=141)

(n=274)

(n=39)

(n=

81)

None

79

98

98

62

67

12

12

74

82

48

47

16

28

97

99

Generalhealthcare

68

79

00

97

24

75

40

42

28

20

00

Psychiatriccare

21

52

230

26

86

84

19

13

65

55

50

31

Private

47

00

00

11

00

66

12

00

M,Male;F,female.

aMix,‘M

edicalattention/surgeryrequired,butnodanger

tolife.

b‘M

edicalattention/surgeryrequired,had/hasdanger

tolife’.


74

Consequences of the attempted suicide and care

The suicide attempt resulted in physical conse-quences and danger to life (assessed by themedical staff and understood as an indicationof the clinical severity of the attempt) in morethan 50% of the cases in Yuncheng (80.2% ofthe females and 66.7% of the males), Chennai(74.6% of the males and 65.9% of the females)and Campinas (52.6% of the males). In theremaining sites, most subjects required acombination of medical attention or surgery,but there was no danger to life (Table 4).

With regards to the type of care, transferto a psychiatric institution ranged from 0%to 34%; in most of the sites it was very low(between 0% and 8% of the cases), with theexception of Campinas (23.9% for women) andTallinn (34% for men).

Practically no referral to any professionalservice was made in Yuncheng for both men(97.4%) and women (98.8%) and in Chennai(97.6% for men, 98.3% for women), whichreflects the non-existence of eligible referralservices in these locations. In Hanoi, Colomboand Karaj the amount of non-referral wasequally dominant among both men and women(46.5–81.7%). In Campinas referral was pri-marily made to a general health-care or primaryhealth-care centre (67.9–79.1%, both sexes).In Durban and Tallinn, the patients weremainly sent to a psychiatric out-patient clinic(50.4–85.7%, both sexes). In four of the eightsites less than one-third of subjects received anytype of referral for follow-up evaluation orcare (Table 4).

A separate question regarding the acceptanceof an offer of professional care, which was notlinked to the referral, was answered positivelyby the majority of subjects, i.e. they would ac-cept to go to the consultation offered. Refusalswere strongest in Colombo (up to 38.5% forfemales).

DISCUSSION

This is the first study to provide detailed infor-mation on cases of suicide attempts from a widerange of developing countries. For several ofthe participating countries, it is the first data onattempted suicides ever collected or publishedboth in national and international periodicals.

The situation in virtually all participatingemergency settings is such that suicide attemptsare not recorded on a routine basis, resultingin a lack of data to estimate rates of suicideattempts. An effort was made to collect forthe first time this basic intake information fromall suicide attempters in the emergency-caresettings.

Despite careful preparations, in some sites afew subjects managed to slip through. In somesites the number was not known (although be-lieved to be very small), in other sites at leastsex and age of those not completing the intakewere known (allowing a comparison of thosewho did and did not participate in the intake),and in a third group of sites all subjects werepart of the intake. Future thorough analysesspecifically addressing sample issues will pro-vide a sense of how representative the reportedcases are.

This sample of attempted suicides identi-fied in emergency rooms of hospitals in eightdeveloping countries is, like those identified indeveloped countries (Diekstra, 1993; Schmidtkeet al. 1996; Latha et al. 1996; Thanh et al. 2005),primarily composed of young adults. Themale : female gender ratio in the eight countriesranged from 1 : 1.1 to 1 : 2.6 which is similar tothat reported in the WHO/EURO multicentrestudy [1 : 0.7 to 1 : 2.3 (Schmidtke et al. 2004)].Unlike reports from developed countries (Lohr& Schmidtke, 2004), a high proportion of thesubjects in this study were married at the timeof their attempt, suggesting that marriage is nota strong protective factor for suicide attemptin developing countries (WHO, 2002b).

Similar to other countries, self-poisoning isthe most common method of suicide attempt,and the ingestion of pesticides, medicationsor other poisons accounted for 69–98% of allsuicide attempts identified in the emergency-care units of the eight sites included in thestudy. Nevertheless, pesticides are a morecommon method of self-poisoning in develop-ing countries, particularly in China, India, andSri Lanka.

These findings strongly support earlier re-ports on the role of pesticide poisoning inattempted and completed suicide in developingcountries (Latha et al. 1996; Eddleston, 2000;Phillips & Li, 2002; Phillips et al. 2002; Gunnell& Eddleston, 2003; Eddleston & Phillips, 2004).


75

It has been shown repeatedly that restrictingthe access to and the availability of the prevail-ing method can be effective in reducing thefrequency of suicide attempts (Bowles, 1995;Roberts et al. 2003).

This result calls for immediate action on thisissue, where it is relevant, including the analysisof regulations, distribution, availability, access,and packaging of these substances, and forprompt intervention after the intoxication, withlocal emphasis on the most used substance, e.g.pesticides in these Asian countries.

Another important finding was the relativelack of professional services for referral ofsuicide attempters. This results in a situationwhere the care is limited to somatic symptomsonly. Even in those places where psychologicalor psychiatric services were available, psy-chiatric assessment and referral were notdelivered in a systematic way or as part of aroutine which is in agreement with a study fromEurope regarding young suicide attempters(Hulten et al. 2000). In these places, the currentsituation leaves plenty of room for improvementof the health services.

Accurate, standardized information on therates and characteristics of medically treatedsuicide attempts is essential to the developmentand evaluation of preventive services, however,the emergency departments of hospitals in bothdeveloped and less-developed countries arenot currently able to collect this information.Our study has highlighted several of the diffi-culties that need to be overcome to rectify thisproblem: incomplete or inaccurate registrationof persons seen in emergency departments ;patients and family members intentionally mis-reporting the cause of the attempted suicideinjury or absconding from the emergency de-partment as soon as possible to avoid stigma(Wasserman, 2001) and (in some cases) legalsanctions; clinicians not recording routinelysuicide attempts as such and, therefore, failingto collect essential information or to providefollow-up referrals, or (in some cases) becausethey wish to avoid legal proceedings. The mag-nitude and causes of the problems vary acrossthe countries included in this study, largelydue to cultural and socio-economic factors.Rectifying these problems will require sub-stantial legal, administrative and attitudinalchanges.

ACKNOWLEDGEMENTS

The study was funded by the Department ofMental Health and Substance Abuse, WorldHealth Organization, where both first authorsare employed. Some field research sites obtainedadditional funding from the following agencies.Hanoi : Swedish International CooperationDevelopment Agency (SIDA), Stockholm,Sweden [within the collaboration between theSwedish National and Stockholm CountyCouncil’s Centre for Suicide Research andPrevention of Mental Ill-Health (NASP) at theInstitute for Psychosocial Medicine (IPM) andthe Department of Public Health Sciences atthe Karolinska Institute and Hanoi MedicalUniversity]. Karaj : Iran National ResearchCenter for Medical Sciences, Tehran, Iran.Tallinn : Estonian Health Insurance Fund,Tallinn, Estonia; the Swedish National andStockholm County Council’s Centre for SuicideResearch and Prevention of Mental Ill-Health(NASP) at the Institute for PsychosocialMedicine (IPM) and the Department of PublicHealth Sciences at the Karolinska Institute,Stockholm, Sweden.

DECLARATION OF INTEREST

None.

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Sisask, M., Värnik, A., Kõlves, K., Konstabel, K. and Wasserman, D. (2008). Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. Nordic Journal of Psychiatry, 62(6): 431-435.

79

Subjective psychological well-being(WHO-5) in assessment of the severityof suicide attemptMERIKE SISASK, AIRI VARNIK, KAIRI KOLVES, KENN KONSTABEL,DANUTAWASSERMAN

Sisask M, Varnik A, Kolves K, Konstabel K, Wasserman D. Subjective psychological well-being(WHO-5) in assessment of the severity of suicide attempt. Nord J Psychiatry 2008;62:431�435.Oslo. ISSN 0803-9488.

An objective way to measure the severity of suicide attempt is to use different psychometricscales. Aspects of suicide risk like suicidal intent, depression, hopelessness and well-being can beassessed and different practical scales are in use to facilitate the risk assessment procedure. Theaims of current study were: 1) to analyse the association between the severity of suicide attemptmeasured by suicidal intent scale and characteristics of emotional status of suicide attemptersmeasured by depression, hopelessness and well-being scales in different gender and age groups;2) to test the applicability of well-being measured by the World Health Organisation well-beingindex (WHO-5) in suicide risk assessment. The data on suicide attempters (n�469) wasobtained in Estonia (Tallinn) by the WHO Suicide Prevention*Multisite Intervention Study onSuicidal Behaviours (SUPRE-MISS) methodology. Different psychometric scales were used tomeasure suicidal intent (Pierce Suicidal Intent Scale) and emotional status (Beck DepressionInventory for depression, Beck Hopelessness Scale for hopelessness, WHO-5 for well-being). Allpsychometric scales correlated well with each other (PB0.05). Low level of well-being associatedwith high level of suicidal intent, depression and hopelessness. Suicidal intent correlated themost strongly with well-being. Analysis by gender and age groups revealed also significantcorrelations with two exceptions only: correlation between suicidal intent and hopelessness didnot reach the significant level in males and in older adults (40�). The WHO-5 well-being scale,which is a short and emotionally positively loaded instrument measuring protective factors, canbe used in settings without psychological/psychiatric expertise in preliminary suicide riskassessment.� Depression, Hopelessness, Severity of suicide attempt, Suicidal intent, Well-being.

Merike Sisask, Estonian-Swedish Mental Health and Suicidology Institute, Oie 39, Tallinn11615, Estonia, E-mail: [email protected]; Accepted 5 December 2007.

Suicide risk assessment is an important issue and at

the same time a complicated task. An objective way

to measure the severity of suicide attempt is to use

different psychometric scales. Aspects of suicide risk like

suicidal intent, depression, hopelessness and well-being

can be assessed and different practical scales are in use to

facilitate the risk assessment procedure (1).Suicidal intent scales are developed to measure the

severity and intensity of suicidal thoughts and plans

(1, 2). One of the most well-known scales for assessment

of the severity of suicidal intent is the Beck Suicide Intent

Scale (3). A comparable scale, essentially a modification

of Beck Suicide Intent Scale, is the Pierce Suicidal Intent

Scale (PSIS) (4). Both scales are in general not used as

clinical suicide risk assessment scales but rather as scalesin research studies to classify suicide attempters.

Empirically defined affective and cognitive experi-

ences of suicidal persons are depression and hopeless-

ness. There are indicators that 60�70% of patients with

acute depression experience suicidal ideas and 10�15%of depressive patients commit suicide (5). Depression is a

psychiatric diagnosis most strongly linked with suicide

(6). The Beck Depression Inventory (BDI) (7) is a self-reported inventory currently widely used both in clinical

practice and research for identifying symptoms of

depression and measuring its severity.

Hopelessness has been defined as ‘‘the system

of cognitive functions with common denominator of

negative expectations for the future’’ (8). Hopelessness

does not necessarily mean only the presence of negative

thoughts, but it is even more strongly correlated withlack of positive thoughts about the future (9). The Beck

# 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As) DOI: 10.1080/08039480801959273

80

Hopelessness Scale (BHS) (8) is one of the most

frequently used self-reported questionnaires in researchof hopelessness and predicting suicide. A one-item

modification of this multiple-item scale has been also

proved to measure hopelessness in an adequate way (10).

Hopelessness is highly associated with depression and

suicidal behaviour (11�14) and it has been considered

a key variable linking depression to suicidal behaviour

(15, 16).

There is rather little research available to the best ofour knowledge about the role of well-being in under-

standing suicidal behaviour. An ecological study has

confirmed the inverse association of suicide rate with life

satisfaction and happiness as indicators of population

well-being (17). The WHO well-being index (WHO-5) is

a relatively new instrument, developed by Bech in the

1990s to measure the subjective level of people’s well-

being (18). The WHO-5 has been found to be a sensitiveand easily used instrument for depression screening

in the primary care (19�22), although it reflects also

aspects other than just the absence of depressive

symptoms (23�25). The need to assess the utility of the

WHO-5 in the context of detecting suicidal ideation has

been pointed out (26).

The aims of current study were:

1) To analyse the association between the severity of

suicide attempt measured by suicidal intent scale

and characteristics of emotional status of suicideattempters measured by depression, hopelessness

and well-being scales in different gender and age

groups;

2) To test the applicability of well-being measured by

WHO-5 in suicide risk assessment.

Material and MethodsData collectionIn 2000, the World Health Organization (WHO)

launched the worldwide intervention study on suicidal

behaviour, SUPRE-MISS (Suicide Prevention*Multisite

Intervention Study on Suicidal Behaviours), with the main

objective of reducing the mortality and morbidity

associated with suicidal behaviour. The study was

conducted in five continents; one of the participating

centres was Estonia (Tallinn). The methodology ofSUPRE-MISS was elaborated by a WHO expert group

and adapted to local conditions (27, 28).

In Estonia, the study was conducted by the Estonian�Swedish Mental Health and Suicidology Institute

(ERSI). The Tallinn Medical Research Ethics Commit-

tee gave approval for the study in Estonia. All suicide

attempters identified between December 2001 and

January 2004 by medical staff in the emergency-caresettings of the Northern Estonian Regional Hospital

were invited to participate in the study. Those who

agreed filled in a consent form and a structured in-depthinterview was conducted as soon as their medical

condition had stabilised. The interviewers were clinically

experienced specialists (psychiatrists and psychologists).

Description of subjectsThe research subjects were 469 suicide attempters, 161(34.3%) males and 308 (65.7%) females. The response rate

was 53% and the main reasons for exclusion were suicide

attempters’ refusal and leaving the hospital before inter-

view was conducted. The interviewed suicide attempters

were representative by gender and age for all suicide

attempters seen at the emergency care department during

the study period. The mean age (9standard deviation, s)

of suicide attempters was 32.6914.1 years*for males31.5911.8 years and for females 33.2915.1 years. The

difference in mean age between males and females was

statistically non-significant (t��1.2, P�0.222). The

suicide attempters were divided in analysis into the

following age groups: youth (15�24 years, n�178,

38.0%), younger adults (25�39 years, n�157, 33.5%)

and older adults (40 and older, n�134, 28.6%).

ScalesFor defining the severity of suicide attempt, a revised

version of the original Pierce Suicidal Intent Scale

(PSIS) was used (4, 28). The scale consisted of 12

questions and possible total score ranged from 0 to 24

(Cronbach’s alpha�0.77; n�448, x�8.24, s�4.42).Higher score refers to more severe suicide attempt.

The occurrence of depression was assessed by the

means of 21-item Beck Depression Inventory (BDI) (7).

The possible range of score was 0 to 63 (Cronbach’s

alpha�0.93; n�469, x�18.90, s�11.35). Higher score

refers to more severe depressive status.

Negative attitude towards the future was assessed on

the Beck Hopelessness Scale (BHS) (8) and on its one-item modification, the Aish & Wasserman scale (10).

The original scale consists of 20 statements to be rated

dichotomously (true vs. false); the total score has a

theoretical range from 0 to 20 (Cronbach’s alpha�0.91;

n�440; x�9.35; s�5.54). The Aish & Wasserman scale

consists of one statement (‘‘My future seems dark to

me’’). To be in line with other scales opposite to the

original scale, in the current research a higher scorerefers to more severe hopelessness.

Assessment of well-being was performed using the

WHO well-being index (WHO-5) (18). Five statements

presented (‘‘I have felt cheerful and in good spirits’’, ‘‘I

have felt calm and relaxed’’, ‘‘I have felt active and

vigorous’’, ‘‘I have felt fresh and rested’’, ‘‘My daily life

has been filled with things that interest me’’) were

assessed on a 6-score scale (from never to always),with the possible total score varying from 0 to 25

M SISASK ET AL.

432 NORD J PSYCHIATRY �VOL 62 �NO 6 �2008

81

(Cronbach’s alpha�0.93; n�466, �10.11, s�5.59).

Higher score refers to better well-being.

Statistical analysisThe statistical analysis was performed with the SPSS

(version 14.0) program. The reliability of scales was

assessed using the internal consistency coefficient*Cronbach’s alpha. The differences of mean scores were

calculated using a t-test for genders and analysis of

variance (ANOVA) for age groups. In assessment of

correlations between the scales, a Spearman correlation

coefficient was used. The level of statistical significancewas set at a�0.05.

ResultsThe mean scores of different scales did not differ by

gender, but increased (in the case of well-being*decreased) statistically significantly with age (Table 1).The correlations between different scales are pre-

sented in Table 2.

Suicidal intent was negatively correlated with well-

being, and positively with depression and hopelessness.

Lower well-being and higher depression or hopelessness

referred to more severe suicidal intent. Suicidal intent

correlated the most strongly with well-being.

Well-being was correlated negatively with impairedemotional status as assessed by all other scales*the

lower well-being the higher score of depression and

hopelessness. Correlation was the strongest with depres-

sion. Multiple-item and one-item hopelessness scales had

similar correlations with other scales with only minor

variations in magnitude of the correlation coefficient.

Correlations between different scales were also on a

significant level in analysis by gender and age groups,with two exceptions only: correlation between suicidal

intent and hopelessness (both multiple-item and on-item

scales) did not reach the significant level in males and in

older adults (40 or more years old).

DiscussionAs expected, the severity of the suicide attempt corre-

lated with the level of depression and hopelessness.

Multiple-item and one-item hopelessness scales had

similar results, which confirms the previous suggestions

that in order to be less stressful for interviewees to

answer, the hopelessness scale can be shortened without

losing important information (10, 29).

Well-being measured by WHO well-being index(WHO-5) turned out to be an important issue, along

with already well-known characteristics and risk factors

of suicide attempt like depression and hopelessness.

Correlations between WHO-5 and other scales were all

at a significant level. Table

1.Meanscoresofdifferentscalesfilled

inafter

suicideattem

pt(total,bygender

andagegroups).

Gender

Agegroup

Total(s)

Males(9

s)Fem

ales(9

s)t-test

P-value

15�24(9

s)25�39(9

s)40�(9

s)F

P-value

PSIS

8.24(9

4.42)

8.01(9

4.54)

8.37(9

4.36)

�0.838

0.402

7.52(9

4.22)

8.21(9

4.20)

9.25(9

4.75)

5.959

0.003

BDI

18.90(9

11.35)

17.68(9

10.73)

19.53(9

11.63)

�1.675

0.095

15.78(9

11.14)

20.01(9

10.41)

21.73(9

11.78)

12.188

B0.001

WHO-5

10.11(9

5.59)

10.71(9

5.36)

9.79(9

5.68)

1.699

0.090

11.36(9

5.68)

9.93(9

4.78)

8.63(9

6.01)

9.485

B0.001

BHS/m

ulti

9.35(9

5.54)

9.69(9

5.41)

9.18(9

5.61)

0.939

0.348

7.85(9

5.27)

9.71(9

5.46)

10.97(9

5.51)

12.854

B0.001

BHS/one

0.51(9

0.50)

0.54(9

0.50)

0.49(9

0.50)

0.220

0.285

0.40(9

0.49)

0.53(9

0.50)

0.63(9

0.48)

8.992

B0.001

PSIS,PierceSuicidalIntentScale;BDI,BeckDepressionInventory;WHO-5,WHO

well-beingindex;BHS/m

ulti,BeckHopelessnessScale(m

ultiple-item);BHS/one,BeckHopelessnessScale(one-

item

‘‘Myfuture

seem

sdark

tome’’).

WELL-BEING AND SEVERITY OF SUICIDE ATTEMPT

NORD J PSYCHIATRY �VOL 62 �NO 6 �2008 433

82

The concept of well-being has a complex multidisci-

plinary nature comprising different dimensions on both

an individual and societal level*economic, social,

physical and psychological (30�32). One possible way

to define well-being is: ‘‘a positive and sustainable state

that allows individuals, groups and nations to thrive and

flourish’’ (33). The five statements of the WHO-5 are

supposed to measure the pure subjective psychological

feeling of a person about his/her well-being (18).The strong side of the WHO-5 is its shortness and

positive questions, which are not too difficult to answer

(34). It has been argued that psychometric scales to be

used in a daily clinical setting should be simple and brief

(1). The positive questions of the WHO-5, shifted

towards measuring cheerfulness and the level of energy,

work in the screening of depression as successfully as the

questions narrowly oriented on depressive symptoms,

which could be hidden by patients because of shame and

stigma associated with psychic disorders (35). It is

known that the WHO-5 also gives many false-positive

results*people with a low score of well-being do notnecessarily suffer from clinical depression (19, 36).

General statements as included in the WHO-5 improve

sensitivity and the negative predictive value of the scale

at the cost of specificity and positive predictive value

(37). Therefore, the low level of well-being screened by

the WHO-5 should lead a specialist in clinical work to

investigate further the severity of depression and hope-

lessness, which are associated with suicidal behaviours.

ConclusionsThe current study demonstrated that in understandingthe severity of the suicide attempt studied, scales

measuring emotional status could be served as useful

instruments. A low level of subjective psychological well-

being is associated with high level of suicidal intent,

depression and hopelessness in suicide attempters. What

is remarkable is that both multiple-item and one-item

hopelessness scales demonstrated similar results, corre-

lating well with each other. Short and positively loadedscales like the WHO-5 measuring protective factors

should be preferred for preliminary suicide risk assess-

ment, especially in settings without psychological/psy-

chiatric expertise. However, the WHO-5 is a screening

instrument to select vulnerable subjects and further

specific suicide risk assessment is mandatory.

Acknowledgements*This paper is based on the data and experienceobtained during the participation of the authors in the WHO MultisiteIntervention Study on Suicidal Behaviours (SUPRE-MISS), a projectfunded by the World Health Organisation and the participating fieldresearch centres.The Tallinn centre obtained additional funding for data collection

and analysis from the following agencies: the Estonian HealthInsurance Fund; the Swedish National and Stockholm CountyCouncil’s Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), the WHO Lead Collaborating Centre at theDepartment of Public Health Sciences, the Karolinska Institute andthe Estonian Scientific Foundation (Project No 7132).The Collaborating Investigators in this study have been

(in alphabetical order): Dr J. Bolhari, Tehran; Professor N. Botega,Campinas; Dr D. De Silva, Colombo; Dr M. Phillips, Beijing;Professor L. Schlebusch, Durban; Dr H. Tran Thi Thanh, Hanoi;Professor A. Varnik, Tallinn; Dr L. Vijayakumar, Chennai.Dr J. M. Bertolote and Dr A. Fleischmann have coordinated the

project at WHO Headquarters, Geneva.Professor D. Wasserman, Stockholm, and Professor D. De Leo,

Brisbane, have acted as scientific advisors for the WHO SUPRE-MISSstudy.A list of other staff contributing to the project can be obtained from

WHO, Geneva.

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3. Beck AT, Schuyler D, Herman I. Development of Suicidal IntentScales. In: Beck AT, Resnick HLP, Lettieri DJ, editors. Theprediction of suicide. Bowie, MD: Charles Press; 1974. p. 45�56.

Table 2. Correlations between different scales filled in aftersuicide attempt (total, by gender and age groups).

PSIS BDI WHO-5 BHS/multi

Total

BDI 0.341*

WHO-5 �0.377* �0.531*

BHS/multi 0.209* 0.664* �0.412*

BHS/one 0.244* 0.562* �0.332* 0.795*

Males

BDI 0.292*

WHO-5 �0.291* �0.502*

BHS/multi 0.133 0.608* �0.448*

BHS/one 0.156 0.535* �0.333* 0.801*

Females

BDI 0.365*

WHO-5 �0.415* �0.543*

BHS/multi 0.254* 0.694* �0.407*

BHS/one 0.295* 0.586* �0.343* 0.790*

Age group 15�24BDI 0.364*

WHO-5 �0.359* �0.538*

BHS/multi 0.231* 0.694* �0.418*

BHS/one 0.282* 0.578* �0.339* 0.764*

Age group 25�39BDI 0.307*

WHO-5 �0.285* �0.507*

BHS/multi 0.181* 0.598* �0.366*

BHS/one 0.214* 0.519* �0.234* 0.784*

Age group 40�BDI 0.273*

WHO-5 �0.408* �0.475*

BHS/multi 0.013 0.641* �0.328*

BHS/one 0.151 0.524* �0.320* 0.785*

*Significant at the 0.05 level. PSIS, Pierce Suicidal Intent Scale; BDI,

Beck Depression Inventory; WHO-5, WHO Well-Being Index; BHS/

multi, Beck Hopelessness Scale (multiple-item); BHS/one, Beck Hope-

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434 NORD J PSYCHIATRY �VOL 62 �NO 6 �2008

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14. Kuo WH, Gallo JJ, Eaton WW. Hopelessness, depression,substance disorder, and suicidality*A 13-year community-basedstudy. Soc Psychiatry Psychiatr Epidemiol 2004;39:497�501.

15. Beck AT, Kovacs M, Weissman A. Hopelessness and suicidalbehavior. An overview. JAMA 1975;234:1146�9.

16. Dyer JA, Kreitman N. Hopelessness, depression and suicidal intentin parasuicide. Br J Psychiatry 1984;144:127�33.

17. Bray I, Gunnell D. Suicide rates, life satisfaction and happiness asmarkers for population mental health. Soc Psychiatry PsychiatrEpidemiol 2006;41:333�7.

18. WHO. Info Package: Mastering depression in primary care.Fredriksborg: World Health Organisation, Regional Office forEurope, Psychiatric Research Unit; 1998.

19. Henkel V, Mergl R, Kohnen R, Maier W, Moller HJ, Hegerl U.Identifying depression in primary care: A comparison of differentmethods in a prospective cohort study. BMJ 2003;326:200�1.

20. Bonsignore M, Barkow K, Jessen F, Heun R. Validity of the five-item WHO Well-Being Index (WHO-5) in an elderly population.Eur Arch Psychiatry Clin Neurosci 2001;251 Suppl 2:II27�31.

21. Hegerl U, Althaus D. [From patient screening to management listin suicide risk. Practical guideline for dealing with depression].MMW Fortschr Med 2003;145:24�7.

22. Lowe B, Spitzer RL, Grafe K, Kroenke K, Quenter A, Zipfel S, etal. Comparative validity of three screening questionnaires forDSM-IV depressive disorders and physicians’ diagnoses. J AffectDisord 2004;78:131�40.

23. Heun R, Burkart M, Maier W, Bech P. Internal and externalvalidity of the WHO Well-Being Scale in the elderly generalpopulation. Acta Psychiatr Scand 1999;99:171�8.

24. Bech P, Olsen LR, Kjoller M, Rasmussen NK. Measuringwell-being rather than the absence of distress symptoms: A

comparison of the SF-36 Mental Health subscale and the WHO-Five Well-Being Scale. Int J Methods Psychiatr Res 2003;12:85�91.

25. Kessing LV, Hansen HV, Bech P. General health and well-being inoutpatients with depressive and bipolar disorders. Nord J Psy-chiatry 2006;60:150�6.

26. Awata S, Bech P, Koizumi Y, Seki T, Kuriyama S, Hozawa A, et al.Validity and utility of the Japanese version of the WHO-Five Well-Being Index in the context of detecting suicidal ideation in elderlycommunity residents. Int Psychogeriatr 2006:1�12.

27. Fleischmann A, Bertolote JM, De Leo D, Botega N, Phillips M,Sisask M, et al. Characteristics of attempted suicides seen inemergency-care settings of general hospitals in eight low- andmiddle-income countries. Psychol Med 2005;35:1467�74.

28. WHO. Multisite Intervention Study on Suicidal BehavioursSUPRE-MISS: Protocol of SUPRE-MISS. Geneva: WHO; 2002.

29. Yip PS, Cheung YB. Quick assessment of hopelessness: A cross-sectional study. Health Qual Life Outcomes 2006;4:13.

30. Diener E, Lucas RE. Subjective emotional well-being. In: LewisM, Haviland-Jones JM, editors. Handbook of emotions, 2ndedition. New York: Guilford Press; 2000. p. 325�37.

31. Huppert FA, Baylis N. Well-being: Towards an integration ofpsychology, neurobiology and social science. Phil Trans R SocLond, B. Biol Sci 2004;359:1447�51.

32. Helliwell JF, Putnam RD. The social context of well-being. PhilTrans R Soc Lond, B. Biol Sci 2004;359:1435�46.

33. Huppert FA, Baylis N, Keverne B. Introduction: Why do we need ascience of well-being? Phil Trans R Soc Lond, B. Biol Sci 2004;359:1331�2.

34. Bech P, Raabaek Olsen L, Nimeus A. Psihometritsheskije shkalootsenki suicidalnogo riska. In: Wasserman D, editor. Suitsid*naprasnaja smert. Tartu: Tartu Ulikooli Kirjastus; 2003. p. 157�63.

35. Henkel V, Mergl R, Coyne JC, Kohnen R, Moller HJ, Hegerl U.Screening for depression in primary care: Will one or two itemssuffice? Eur Arch Psychiatry Clin Neurosci 2004;254:215�23.

36. Henkel V, Mergl R, Kohnen R, Allgaier AK, Moller HJ, Hegerl U.Use of brief depression screening tools in primary care: Con-sideration of heterogeneity in performance in different patientgroups. Gen Hosp Psychiatry 2004;26:190�8.

37. Primack BA. The WHO-5 Wellbeing Index performed the best inscreening for depression in primary care. ACP J Club 2003;139:48.

Merike Sisask, Estonian-Swedish Mental Health and SuicidologyInstitute, Tallinn, Estonia; Tallinn University, Estonia.Airi Varnik, Estonian-Swedish Mental Health and SuicidologyInstitute, Tallinn, Estonia; Tallinn University, Estonia; University ofTartu, Estonia.Kairi Kolves, Estonian-Swedish Mental Health and SuicidologyInstitute, Tallinn, Estonia.Kenn Konstabel, University of Tartu, Estonia; National Institute forHealth Development, Tallinn, Estonia.Danuta Wasserman, National Prevention of Suicide and MentalIll-Health (NASP) at Karolinska Institute and Stockholm CountryCouncil’s Centre for Suicide Research and Prevention, WHO LeadCollaborating Centre of Mental Health Problems and Suicide AcrossEurope, Stockholm, Sweden.

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Sisask, M., Värnik, A. and Kõlves, K. (2009). Severity of attempted suicide as measured by the Pierce Suicidal Intent Scale. Crisis, 30(3): 136-143.

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M. Sisask et al.: Attempted Suicide and Suicidal IntentCrisis 2009; Vol. 30(3):136–143© 2009 Hogrefe Publishing

Research Trends

Severity of Attempted SuicideasMeasured by the

Pierce Suicidal Intent ScaleMerike Sisask1,2, Kairi Kõlves1,3, and Airi Värnik1,2,4,5

1Estonian-SwedishMental Health and Suicidology Institute, Estonian Centre of Behavioral and HealthSciences, Tallinn, Estonia, 2Tallinn University, Tallinn, Estonia, 3Australian Institute for Suicide Researchand Prevention (AISRAP), Brisbane, Australia, 4University of Tartu, Tartu, Estonia, 5National Preventionof Suicide andMental Ill-Health (NASP) at Karolinska Institute and Stockholm County Council’s Centrefor Suicide Research and Prevention, WHO Lead Collaborating Centre of Mental Health Problems and

Suicide Across Europe, Stockholm, Sweden

Abstract. Background: Suicidal intent is an essential feature of suicidal behavior. Previous research has been controversial and the needfor further evidence has been pointed out. Aims: The aim of the present study was to characterize the severity of attempted suicide byextracting components of suicidal intent and analyzing levels of suicidal intent by gender, age, and variables indicating the severity ofattempted suicide. Methods: Data on suicide attempters (N = 469) were collected in Estonia using WHO SUPRE-MISS methodology.To measure suicidal intent, a revised version of the Pierce Suicidal Intent Scale (PSIS) was used. Results: The level of suicidal intentwas not gender-dependent, but rose with age. Males and females were also similar in terms of discrete components. Classified in agegroups, their unequivocally expressed “wish to die” was similar, but equivocal communication (components termed “arrangements” and“circumstances”) increased with age. Middle-aged groups scored higher for the “alcohol/drugs” component. Psychiatric diagnosis, methodof attempting suicide, and duration of hospitalization were linked to suicidal intent, but danger to life as assessed by interviewers wasnot. Conclusions: In suicide-risk assessment, results from a Suicidal Intent Scale contribute to clinical observation and add valuableinformation about a suicidal person’s real intention.

Keywords: suicide attempt, Pierce Suicidal Intent Scale, components of suicidal intent, gender and age differences

IntroductionSuicidal intent is an essential component of any definitionof suicide and suicidal behavior. This is primarily becauseit permits a distinction to be drawn between accidental andsuicidal behavior (Andriessen, 2006). Suicidal intent hasbeen defined as the seriousness or intensity of a person’swish to terminate his or her life (Beck, Schuyler, & Her-man, 1974). The term level of suicidal intent is used todescribe the intensity of a death wish (Hjelmeland & Haw-ton, 2004).

The development of suicidal behavior has been charac-terized by the model of suicidal process, and suicidality hasbeen described as a continuum from the lowest (wearinessof life, suicidal ideation) to the highest (serious suicide at-tempt and completed suicide) level of suicidality (Maris,Berman, Silverman, & Bongar, 2000; Wasserman, 2001).Suicidal intent evolves during the suicidal process and lev-els of suicidal intent at different stages of the suicidal pro-

cess may vary. Suicidal intent consists in a consciously ex-pressed wish to be dead, but there are also nonsuicidal con-scious or unconscious purposes, such as trying to manipu-late others or escape from an intolerable situation (Andries-sen, 2006; Hjelmeland, 1995; Hjelmeland & Hawton,2004; Hjelmeland & Knizek, 1999; Michel, Valach, &Waeber, 1994). Moreover, suicidal behavior has clear ver-bal communication aspects, but nonverbal suicidal com-munication also expresses suicidal intent, one example be-ing the particular way in which a suicidal act is carried out,especially in the presence of others (Lester, 2001; Wasser-man, 2001).

Psychometric scales are available to measure levels andvarious aspects of suicidal intent. One of the best-knownscales, the Beck Suicide Intent Scale (BSIS), is not a sui-cide-risk scale as such, but rather a scale designed for usein research studies to classify suicide attempters (Bech,Raabaek Olsen, & Nimeus, 2001; Beck, Kovacs, & Weiss-man, 1979; Beck et al., 1974). A comparable scale, the

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Pierce Suicidal Intent Scale (PSIS), was devised to measurethe severity of suicidal intent among suicide attempters(Pierce, 1977). Pierce’s intention was to design and test amore objective scale for measuring suicidal intent than theBSIS, but the outcome was merely a modification.

Although some aspects and meanings of suicidal intenthave been studied, the results of various studies have beencontroversial and the need for further evidence on this is-sue, focusing particularly on nonfatal suicidal behavior andgender-age differences, has been pointed out (Andriessen,2006; Hjelmeland & Hawton, 2004; Hjelmeland et al.,2000).

The aim of the present study was to characterize the se-verity of attempted suicide by extracting the componentsof suicidal intent and analyzing levels of suicidal intent bygender, age, and variables indicating the severity of at-tempted suicide.

Material and Methods

In 2000 the World Health Organization (WHO) launchedthe worldwide intervention study on suicidal behaviorSUPRE-MISS (Suicide Prevention – Multisite InterventionStudy on Suicidal Behaviors). Its main objective was toreduce the mortality and morbidity associated with suicidalbehavior. The study was conducted on five continents, andone of the participating centers was Estonia (Tallinn). Themethodology of SUPRE-MISS was elaborated by a WHOexpert group and adapted to local conditions (Fleischmannet al., 2005; WHO, 2002).

In Estonia, the study was conducted by the Estonian-Swedish Mental Health and Suicidology Institute (ERSI).The Tallinn Medical Research Ethics Committee approvedthe Estonian study. All suicide attempters identified bymedical staff in the emergency-care settings of the North-ern Estonian Regional Hospital between December 2001and January 2004 were invited to participate in the study.Those who agreed filled in a consent form, and structuredin-depth interviews were conducted as soon as their medi-cal condition had stabilized. The interviewers were clini-cally experienced specialists (psychiatrists and psycholo-gists).

The research subjects were 469 suicide attempters, 161

(34.3%) males and 308 (65.7%) females. The suicide at-tempters’ mean age was 32.6 years (SD ± 14.1), 31.5 (SD ±11.8) for males and 33.2 (SD ± 15.1) for females. The dif-ference in mean age between males and females was sta-tistically nonsignificant, t = –1.2, p = .222. The suicide at-tempters enrolled constituted 53% of all suicide attemptersseen at the emergency department during the study period.Among the suicide attempters enrolled, females wereslightly overrepresented, χ² = 9.7, df = 1, p = .002. The dif-ference in mean ages of the enrolled and nonenrolled sui-cide-attempter groups was not statistically significant, t =0.7, p = .480. For analysis, suicide attempters were dividedinto five age groups (Table 1).

For measuring suicidal intent, a revised version of theoriginal Pierce Suicidal Intent Scale (PSIS) was used(Pierce, 1977; WHO, 2002). The scale consisted of 12questions and the possible total score ranged from 0 to 24:the higher the score, the more severe the suicide attempt.The internal consistency of PSIS was good (Cronbach’sα = 0.77). Three research subjects with three or more miss-ing PSIS responses were excluded from the final analysis.Two subjects with two missing responses and 16 subjectswith one missing response were included in the analysis.

To characterize the severity of attempted suicide, thefollowing variables were chosen for analysis: psychiatricdisorders, method of attempting suicide, duration of hos-pitalization after the suicide attempt, and interviewers’assessment regarding the physical consequences of anddanger to life entailed by the suicide attempt. Interview-ers coded psychiatric disorders and method of attemptingsuicide according to the ICD-10. Psychiatric diagnosesof 54 suicide attempters interviewed by psychologistswere missing. The group with missing diagnoses did notdiffer from the other subjects in terms of gender, χ² = 2.8,df = 1, p = .092, or mean age, t = 0.4, p = .698. Psychi-atric diagnoses and method of attempting suicide weredivided into categories for analysis. Psychiatric diagnos-es were categorized as: None, affective disorders(F30–F39), acute stress reaction (F43.0), schizophrenia(F20–F29), or other. Method of attempting suicide wascategorized as: poisoning (X60– X69), sharp objects(X78), and other (hard) methods. Duration of hospitaliza-tion after the suicide attempt was calculated according tothe date and time of admission and discharge from thehospital. For analysis, the following time periods were

Table 1. Description of suicide attempters by gender and by age groups

Males Females Total

Age group N % N % N %

15–24 60 37.3 118 38.3 178 38.0

25–34 50 31.1 64 20.8 114 24.3

35–44 26 16.1 57 18.5 83 17.7

45–54 18 11.2 44 14.3 62 13.2

55+ 7 4.3 25 8.1 32 6.8

Total 161 100.0 308 100.0 469 100.0

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chosen: 1 day, 2 days, 3 days, 4–7 days, over 7 days.Finally, the interviewers were asked to choose an answerregarding the physical consequences and the danger tolife for the attempted suicide as given in the interviewform. The possible answers were: (1) no significant phys-ical harm, no medical treatment required, (2) medical at-tention/surgery required, but no danger to life, (3) medi-cal attention/surgery required, had/has danger to life.

Statistical analysis was performed using the SPSS(version 14.0) program. Statistical methods were selectedin accordance with the nature of the variables. To extractthe factors of the PSIS, the procedure of principal com-ponents with varimax rotation was used. Scores in termsof single PSIS components were calculated on the basisof variables combined as a single factor. Differences be-tween mean scores were calculated using the t-test forgender and analysis of variance (ANOVA) for age groupsand other variables. Spearman’s rank correlation coeffi-cient was calculated to examine the relationships be-tween gender, age, and PSIS components. The level ofstatistical significance was set at p = .05.

Results

The PSIS variables were categorized as four factors thatdescribed 62.1% of the total variance (Table 2). The firstfactor, Wish to Die, comprised variables concerning the in-tensity of the suicide attempter’s expectations of lethal out-come and opinion about the lethality of the method chosen.The second factor, Arrangements, referred to verbal andnonverbal suicidal communication before the suicide at-tempt. The third, Circumstances, determined the possibilityof intervention and prevention of fatal outcome. The fourth,Alcohol/Drugs, specified whether the person had con-sumed alcohol or drugs before the suicide attempt andwhether such substances were used as facilitating means.Based on ratings for these factors, new scores characteriz-ing the components of suicidal intent were calculated.

There were no statistically significant gender differencesin mean total scores for suicidal intent. Analysis by agegroups, on the other hand, revealed statistically significantdifferences in mean total scores of suicidal intent, and theseincreased with age (Table 3).

Table 2. Factor analysis (principal component analysis with varimax rotation) of Pierce Suicidal Intent Scale (PSIS) filledin after suicide attempt

Components (factors) Variables Factor loadings

Wish to die (F1) Stated intent .886 .087 .160 .053

Purpose of the act .876 .073 .112 –.002

Predictable outcome .762 .267 .251 .060

Arrangements (F2) Final acts in anticipation –.045 .756 .057 .042

Preparations .167 .649 .231 –.123

Suicide note .145 .694 .110 .152

Communication .268 .519 –.320 .136

Circumstances (F3) Isolation .065 .129 .740 .165

Timing .264 .052 .714 –.241

Precautions against rescue .156 .409 .461 –.290

Acting to gain help .200 .021 .613 .289

Alcohol/drugs (F4) Relation with alcohol and drugs .075 .105 .095 .884

Table 3. Mean scores on Pierce Suicidal Intent Scale (PSIS) and its components (factors), suicide attempters, by genderand age group

Total(SD)

Gender Age Group

Males(SD)

Females(SD)

t-test p value 15–24(SD)

25–34(SD)

35–44(SD)

45–54(SD)

55+(SD)

F p values

Total score of PSIS 8.2(± 4.4)

8.0(± 4.5)

8.4(± 4.4)

–0.8 .402 7.5(± 4.2)

8.0(± 4.3)

8.3(± 4.3)

10.0(± 4.7)

9.7(± 4.7)

4.7 .001

Wish to die (F1) 1.1(± 1.6)

1.1(± 1.6)

1.1(± 1.5)

–0.2 .853 1.0(± 1.5)

1.1(± 1.5)

1.0(± 1.6)

1.3(± 1.8)

1.2(± 1.5)

0.6 .701

Arrangements (F2) 3.5(± 2.0)

3.4(± 2.0)

3.5(± 2.1)

–0.5 .631 3.2(± 1.9)

3.3(± 2.0)

3.5(± 2.1)

4.0(± 2.2)

4.2(± 2.2)

2.9 .021

Circumstances (F3) 3.4(± 2.1)

3.2(± 2.0)

3.5(± 2.1)

–1.5 .145 3.0(± 2.1)

3.2(± 1.9)

3.4(± 2.0)

4.2(± 1.9)

4.2(± 2.0)

5.5 <.001

Alcohol/drugs (F4) 0.4(± 0.6)

0.4(± 0.6)

0.4(± 0.6)

0.8 .430 0.3(± 0.6)

0.4(± 0.6)

0.5(± 0.7)

0.5(± 0.7)

0.2(± 0.5)

2.8 .25

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As for the mean total score, there were no statisticallysignificant gender differences in terms of single compo-nents. For the age groups, differences in the mean scoresof the following components were statistically significant:Arrangements, Circumstances, and Alcohol/Drugs (Table3). Scores for Arrangements and Circumstances rose withage. Mean scores for Alcohol/Drugs were highest in themiddle age groups (35–44 and 45–54 years) and lowest inthe oldest age group (55+). Mean scores for Wish to Dieshowed no age-group differences.

Correlation analysis provided no evidence of relation-ship between gender and suicidal intent. Positive correla-tions between age and suicidal intent were statistically sig-nificant in terms of total scores for suicidal intent and thescores of its two components (Arrangements and Circum-stances; see Table 4).

Mean scores for suicidal intent showed statistically signif-icant differences with respect to the following variables char-acterizing the severity of attempted suicide: psychiatric diag-nosis, method of attempting suicide, and duration of hospital-ization after the suicide attempt (Table 5). Suicide attempterswith serious psychiatric diagnoses (affective disorders orschizophrenia) had higher mean scores for suicidal intent,while those with an acute stress reaction or other diagnosis,or who had no diagnosis, had a lower level of suicidal intent.Mean scores for suicidal intent were highest among suicideattempters who used poisoning as their method of attemptingsuicide, followed by those who used other (hard) methodsand self-harm by sharp objects. Suicide attempters whostayed in the hospital for 3 days after the suicide attempt hadhigher mean scores for suicidal intent than those whose hos-pital stays were shorter or longer. There were no significantdifferences in mean scores between the groups in terms ofphysical consequences and danger to life, as assessed by theinterviewers (Table 5).

Discussion

Components of Suicidal Intent

As extracted in our study, the four different components ofsuicidal intent were very clearly differentiated on the PSIS.These four were consciously expressed purpose and opin-

Table 4. Pierce Suicidal Intent Scale (PSIS) and its compo-nents (factors) among suicide attempters, correla-tion with gender and age

Gender Age

Pierce Suicidal Intent Scale (PSIS) .050 .164*

Wish to die (F1) .027 .027

Arrangements (F2) .023 .130*

Circumstances (F3) .066 .172*

Alcohol/drugs (F4) –.048 .056

Spearman’s rank correlation coefficient significant at .05 level.

Table 5. Mean scores on Pierce Suicidal Intent Scale (PSIS), suicide attempters, for variables characterizing severity ofsuicide attempt

N PSIS score (SD) F p value

Psychiatric disorders*

None 3 6.0 (± 2.0)

Affective disorders (F30-F39) 242 8.9 (± 4.4)

Acute stress reaction (F43.0) 87 6.5 (± 3.7) 6.7 < .001

Schizophrenia (F20-F29) 43 8.4 (± 4.9)

Other 37 6.7 (± 3.2)

Method of suicide attempt*

Poisoning (X60–X69) 378 8.6 (± 4.4)

Sharp objects (X78) 50 6.2 (± 3.9) 8.2 < .001

Other (hard) methods 38 7.2 (± 4.1)

Duration of hospitalization after suicide attempt

1 day 136 7.8 (± 4.0)

2 days 51 9.1 (± 4.2)

3 days 60 10.2 (± 4.4) 6.4 < .001

4–7 days 92 8.9 (± 4.5)

over 7 days 123 7.1 (± 4.6)

Physical consequences and danger to life**

No significant physical harm, no medical treatment required 14 6.9 (± 4.9)

Medical attention required, but no danger to life 267 8.4 (± 4.2) 0.8 .442

Medical attention required, had danger to life 185 8.2 (± 4.7)

*According to ICD-10 codes; **according to interviewer’s assessment.



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ion about potential lethality of the act, termed a Wish toDie; long-term preparations and suicidal communication,termed Arrangements; short-term and immediate prepara-tions, known as Circumstances; and the role played in thecurrent suicide attempt by alcohol and/or drug consump-tion, expressed as Alcohol/Drugs. All these componentsare important indicators in characterizing the nuances ofthe suicidal process before the suicide attempt. To the bestof our knowledge, there has been no previous research ona PSIS factor structure, although factor analyses of theBSIS have been published. Diaz et al. (2003) carried out areview of the literature and linked it to their own study.Although current and prior studies are not directly compa-rable, owing to methodological considerations, and thenumber of factors extracted varies from two to four, somegeneralizations can be made. Two broadly common factors,referred to differently in other studies, were expected le-thality (described in the present study as the Wish to Die)and planning (Arrangements and Circumstances in the pre-sent study). The factor known as Alcohol/Drugs in the pre-sent study was distinct from factors in other studies.

The importance of direct and indirect, verbal and non-verbal communication in the development of the suicidalprocess has been recognized before (Lester, 2001; Wasser-man, 2001), and these aspects also characterize the level ofsuicidal intent of suicide attempters in the present study. Asstated in a previous study, what patients say should haveimplications when intervention and follow-up are consid-ered (Hjelmeland, 1995).

Gender Differences

Gender-specific investigation showed that males and fe-males had similar levels of suicidal intent. Previous re-search on suicidal intent has yielded different results: Somehave shown higher scores among males (Harriss, Hawton,& Zahl, 2005; Haw, Hawton, Houston, & Townsend,2003), but there are also studies showing higher scoresamong females (Hamdi, Amin, & Mattar, 1991) or findingno gender differences (Denning, Conwell, King, & Cox,2000; Dyer & Kreitman, 1984; Hjelmeland & Hawton,2004; Hjelmeland, Knizek, & Nordvik, 2002; Niméus, Al-sén, & Träskman-Bendz, 2002).

In the epidemiology of suicidal behavior, significantgender differences have been observed. In Europe the av-erage male-to-female suicide ratio is 4:1 and the male-to-female attempted-suicide ratio is 1:1.5 (Schmidtke et al.,2004). In Estonia, 80% of suicides are committed by men(Värnik, Kõlves, & Wasserman, 2005), while women carryout 61% of suicide attempts (Sisask, 2005). There is also astudy asserting major gender differences in the course ofthe suicidal process: The median interval from the first sui-cidal communication to the suicide was found to be shorterin men than in women (Runeson, Beskow, & Waern, 1996).Based on these differences, it would be plausible to assumethat gender may play an important role in other aspects of

suicidal behavior, such as suicidal intent, as well. It hasbeen argued that male suicide attempts are more likely tobe “failed” suicides, while female suicide attempts maymore frequently stem from factors other than a desire tocommit suicide, such as a wish to communicate distress andthe need for help (Hjelmeland et al., 2000).

The level of suicidal intent among suicide attempters iseasily measurable, but the level of suicidal intent of personswho have committed suicide remains mostly unknown.One study measuring the suicidal intent of people who diedby suicide showed no gender differences in scores for sui-cidal intent, although men chose more violent methods(Denning et al., 2000).

The results of our study corroborated the studies that hadfound no gender differences in suicidal intent. Evidently,we must accept the fact that, despite epidemiological gen-der differences, people who commit suicide and those whomake serious suicide attempts form two overlapping pop-ulations that are far more alike than different (Beautrais,2001).

Age Differences

The results of the present study showed that the level ofsuicidal intent rose with age. Suicidal intent has also beenfound in some previous studies to be correlated with age,i.e., older people have higher scores for suicidal intent (Dy-er & Kreitman, 1984; Harriss et al., 2005). However, somestudies have found that actual intent does not vary greatlywith age (Haw et al., 2003; Hjelmeland & Hawton, 2004).

One surprising finding was the similarity across agegroups of the mean score for the Wish to Die component.Scores for this component might be expected to rise withage, since this was true of total scores for suicidal intent.The two components characterizing the preparations beforea suicide attempt (Arrangements and Circumstances)showed that older people prepared their suicide attemptmore carefully and planned it in greater detail. Suicidal be-havior, especially with a nonfatal outcome, is frequently acommunication act that is not prompted by any real wishto die, in the literature termed a “cry for help” (Farberow& Shneidman, 1961). Analysis of the age variable in cur-rent research showed that suicide attempts are often of acommunicative nature among younger people, in particu-lar: Their arrangements for a fatal outcome were less wellprepared and the circumstances in which the suicidal actswere committed were chosen to make interruption moreprobable.

Another component of suicidal intent that was not foundto increase with age was Alcohol/Drugs. The role of alco-hol or drugs in facilitating suicide attempts was largestamong the middle age groups. According to Kõlves, Vär-nik, Tooding, & Wasserman (2006), among suicide victimsin Estonia, middle-aged men are the highest risk group foralcohol abuse and dependence. It must be borne in mindthat in the present study the component of Alcohol/Drugs



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does not differentiate between alcohol abusers and non-abusers, and results should, therefore, be interpreted withcare. It is known from a previous study that alcohol-de-pendent suicide attempters obtain relatively low scores onthe Suicidal Intent Scale. But although these patients maylack a strong wish to die, they are nonetheless at high riskfor making fatal suicide attempts (Nielsen, Stenager, &Brahe, 1993).

Applicability in Clinical Practice

The question has arisen whether a tool like the PSIS, de-veloped for research purposes, should be used in the sameway in practice, given its inability to reflect the dynamicnature of suicidal behavior (Lyons, Price, Embling, &Smith, 2000). However, previous research has suggestedthat the level of suicidal intent appears to be a powerfulpredictor of eventual suicide after attempted suicide (Hjel-meland, 1996; Niméus et al., 2002; Suominen, Isometsa,Ostamo, & Lonnqvist, 2004). Although a higher level ofsuicidal intent at the time of the suicide attempt has beenfound to be a risk factor for possible future suicide, it hasbeen admitted that a Suicidal Intent Scale cannot forecastwhich specific patients will die by suicide. Nevertheless,information about suicidal intent is still valuable in clinicalsuicide-risk assessment (Harriss & Hawton, 2005).

Other variables included in the analysis as possible char-acteristics of the severity of suicide attempt (psychiatricdisorders, method of attempting suicide, duration of hospi-talization, interviewer’s assessment on lethality) providesome hints for discussion around the construct validity ofthe PSIS. Psychiatric disorders have been clearly linked tosuicidal behavior (Joiner, Brown, & Wingate, 2005) andthe results of the present study did, indeed, confirm the roleof psychiatric disorders in the suicidal process. Suicide at-tempters with serious psychiatric conditions, such as affec-tive disorders (mainly depression) and schizophrenia, hadhigher levels of suicidal intent than others.

The apparent physical danger of the method of attempt-ing suicide chosen (an overdose) has been found to be apoor and potentially misleading measure of how much apatient may have wanted to die (Hawton, 2000). This wascorroborated by the present study. Although poisoning hasbeen classified as a “soft” suicide method compared withother methods (Spicer & Miller, 2000), the suicidal-intentlevel of suicide attempters using poisoning has been shownto be higher than that of others. Suicide attempters are prob-ably incapable of adequately assessing the potential lethal-ity of drugs or substances they ingest. The lowest level ofsuicidal intent was found among suicide attempters whoused sharp objects for self-harm. These persons are mostlikely to be “habitual self-harmers,” who behave in self-de-structive ways without being highly suicidal (Skegg, 2005).

In terms of the duration of hospitalization after the sui-cide attempt, suicidal intent was strongest among thosespending 3 days in the hospital. This is the period needed

for stabilization of the suicide attempter’s condition. Sui-cide attempters spending less or more time in hospital hadlower mean scores for suicidal intent. It is very likely thatpersons committing less severe suicide attempts spend upto 2 days in the hospital, but no more. Suicide attempterswho stay in the hospital for long periods probably sufferfrom complications they did not initially mean to provoke,and this may explain their lower level of suicidal intent. Allin all, conclusions about the severity of attempted suicidebased on the duration of hospitalization should be drawncarefully, since in every single case the physical conse-quences are not only the outcome of the current suicideattempt, but also depend on broader background factors,such as the general health and fitness of the suicide attempt-er, or the availability and effectiveness of healthcare ser-vices.

One finding of our study was that interviewers did notsucceed in differentiating among suicide attempters ac-cording to their level of suicidal intent while assessing thephysical consequences, need for medical attention/treat-ment, and danger to life of the suicide attempt. Neverthe-less, this statement does not disparage the interviewers’ en-tire contribution, since there are indications that any ques-tion in a Suicidal Intent Scale can assess a suicidal person’sreal intention more precisely than a clinician’s objectivelyobserved assessment of the potential lethality of the suicideattempt (Watson, Goldney, Fisher, & Merritt, 2001).

Methodological Considerations

It is questionable whether the results of the present studyare comparable with other results from different studies onsuicidal intent. The first problem associated with compar-ison is the potential variation in definitions and criteria usedfor selecting research subjects (“attempted suicide,” “para-suicide,” “serious suicide attempt,” “deliberate self-harm”). Controversial results from different studies canprobably also be ascribed to disparate ways of measuringsuicidal intent. Methodologically uniform cross-culturalcomparison on this issue would be most welcome.

Conclusions

In conclusion, the present study demonstrated that, in thePierce Suicidal Intent Scale (PSIS), four components char-acterizing the nuances of the suicidal process before at-tempted suicide were very clearly differentiated. The levelof suicidal intent was not gender-dependent, but increasedwith age. Males and females were also similar with respectto individual components of suicidal intent. Althoughscores for the unequivocally expressed Wish to Die com-ponent were similar among all age groups, scores for moreequivocal communication (components termed Arrange-ments and Circumstances) increased with age. The Alco-



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hol/Drugs component had higher scores among the middleage groups. Level of suicidal intent was associated withpsychiatric diagnosis, method of attempting suicide, andduration of hospitalization after suicide attempt. In the in-terviewers’ assessment, there were no differences in levelof suicidal intent among groups of suicide attempters cat-egorized in terms of the physical consequences and dangerto life owing to the suicide attempt. The level of suicidalintent as measured by a Suicidal Intent Scale is valuableinformation on suicidal person’s true intention and couldhelp clinical observation performed by a specialist in sui-cide-risk assessment.

Acknowledgments

This paper is based on the data and experience obtainedduring the authors’ participation in the WHO MultisiteIntervention Study on Suicidal Behaviors (SUPRE-MISS),a project funded by the World Health Organization and theparticipating field research centers.

The Tallinn center obtained additional funding from thefollowing agencies: The Estonian Health Insurance Fund;the Swedish National and Stockholm County Council’sCentre for Suicide Research and Prevention of Mental Ill-Health (NASP) at the Institute for Psychosocial Medicine(IPM), Department of Public Health Sciences, KarolinskaInstitute; the Estonian Scientific Foundation (ProjectNo. 6799, “The role of alcohol in the suicide process andin prevention of suicidal behavior,” and Project No. 7132,“Suicide trend in Estonia during independence: What arethe associations with sociopolitical, economic, and publichealth indicators?”); the European Social Foundation(Measure 1.1, Project No 1.0101–0267).

The Collaborating Investigators in this study have been(in alphabetical order): Dr. J. Bolhari, Tehran; Prof. N.Botega, Campinas; Dr. D. De Silva, Colombo; Prof. V.T.Nguyen, Hanoi; Dr. M. Phillips, Beijing; Prof. L. Schle-busch, Durban; Dr. A. Värnik, Tallinn; and Dr. L. Vijaya-kumar, Chennai. Dr. J.M. Bertolote and Dr. A. Fleischmannhave coordinated the project at WHO Headquarters, Gene-va. Prof D. De Leo, Brisbane and Prof. D. Wasserman,Stockholm have acted as scientific advisors. A list of otherstaff contributing to the project can be obtained fromWHO, Geneva.

Thanks are due to Clare James for her thorough linguis-tic and stylistic revision of the manuscript. Special grati-tude belongs to Prof. D. Wasserman for suggestions con-cerning the focus of the present paper.

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About the authors

Merike Sisask, MSc, Executive Director and Researcher at theEstonian-Swedish Mental Health and Suicidology Institute(ERSI), has a bachelor’s degree in law (1991) and has worked asa psychological counselor (2003). She also holds a master’s de-gree in public health (2005) and is presently a PhD student insociology at Tallinn University (2006–2010).

Kairi Kõlves, PhD, is Researcher at the the Estonian-SwedishMental Health and Suicidology Institute (ERSI). She holds abachelor’s degree (1999), a master’s degree (2001), and a doctoraldegree (2006) in sociology from the University of Tartu. She ispresently Research Fellow at the Australian Institute for SuicideResearch and Prevention (AISRAP, 2008/2009).

Airi Värnik, MD, PhD, is founder and Director of the Estonian-Swedish Mental Health and Suicidology Institute (ERSI). Sheholds a doctoral degree in gerontopsychiatry from Leningrad Be-hterev’s Psycho-Neurological Scientific Research Institute (1973)and a doctoral degree in psychiatry from the Karolinska Institute(1997). She is an expert on forensic psychiatry, professor at Tal-linn University, and a visiting professor at the the Karolinska In-stitute as well as a full member of the International Academy ofSuicide Research.

Merike Sisask

Õie 39Tallinn 11615EstoniaTel./Fax +372 651 6550E-mail [email protected]



Sisask, M., Värnik, A., Kõlves, K., Bertolote, J. M., Bolhari, J., Botega, N. J., Fleischmann, A., Vijayakumar, L. and Wasserman D. (2010). Is Religiosity a Protective Factor Against Attempted Suicide: A Cross-Cultural Case-Control Study. Archives of Suicide Research, 14(1): 44-55.

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Is Religiosity a ProtectiveFactor Against AttemptedSuicide: A Cross-CulturalCase-Control Study

Merike Sisask, Airi Varnik, Kairi Kolves, Jose M. Bertolote,Jafar Bolhari, Neury J. Botega, Alexandra Fleischmann,Lakshmi Vijayakumar, and Danuta Wasserman

This cross-cultural study investigates whether religiosity assessed in three dimensionshas a protective effect against attempted suicide. Community controls (n¼ 5484)were more likely than suicide attempters (n¼ 2819) to report religious denominationin Estonia (OR¼ 0.5) and subjective religiosity in four countries: Brazil(OR¼ 0.2), Estonia (OR¼ 0.5), Islamic Republic of Iran (OR¼ 0.6), andSri Lanka (OR¼ 0.4). In South Africa, the effect was exceptional both for religiousdenomination (OR¼ 5.9) and subjective religiosity (OR¼ 2.7). No effects werefound in India and Vietnam. Organizational religiosity gave controversial results.In particular, subjective religiosity (considering him=herself as religious person)may serve as a protective factor against non-fatal suicidal behavior in some cultures.

Keywords attempted suicide, case-control study, cross-cultural study, religiosity, WHO

SUPRE-MISS

INTRODUCTION

Since Durkheim (1897=2002), researchfindings on the impact of religiosity onsuicidal behaviors has tended to favor theidea of inverse association and protectiveeffect. Although exceptional and contro-versial findings on this issue cannot bedenied, a higher level of religiosity indicatesa lower level of suicidality.

Due to conceptual and methodologicaldiscrepancies, most of the studies per-formed so far are hardly comparable. Themajority of studies have been ecologicalby design and relatively few individual-levelfindings have been reported. Furthermore,while the majority of studies have been

conducted in developed countries andbased predominantly on US data, less workhas been done in developing countries,within the Eastern cultural system or inmore secularized societies (Colucci &Martin, 2008; Stack & Kposowa, 2008;Vijayakumar, John, Pirkis et al., 2005).

Koenig and colleagues (2001) havedefined religion as an organized system ofbeliefs, practices, rituals, and symbolsdesigned to facilitate closeness to thesacred or transcendent. However, religionis a wide concept that is comprised ofdifferent dimensions. The present studyfocuses on three dimensions of religion:religious denomination, organizationalreligiosity, and subjective religiosity.

Archives of Suicide Research, 14:44–55, 2010Copyright # International Academy for Suicide ResearchISSN: 1381-1118 print=1543-6136 onlineDOI: 10.1080/13811110903479052

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Durkheim illustrated the protectiveeffect provided by religious denomi-nation via social integration and regu-lation with the lower suicide ratesreported in Catholic countries comparedwith Protestant countries (Durkheim,1897=2002). A comparison betweenIslam and Christianity has shown thatthe strong degree of integration betweenindividual and society developed byfollowers of the Islamic tradition has areducing effect on suicide rate (Bertolote& Fleischmann, 2002; Simpson &Conklin, 1988). Although several studieshave supported Durkheim’s classicalfindings (Dervic, Oquendo, Grunebaumet al., 2004; Faria, Victora, Meneghelet al., 2006), others doubt the effect ofreligious denomination as a measure ofreligious integration and regulation inthe contemporary world (Moreira-Almeida, Neto, & Koenig, 2006; Neeleman,de Graaf, & Vollebergh, 2004), partiallydue to the growing convergence ofCatholicism and Protestantism (Stack,1983). Regardless of type, religion ingeneral may provide protection fromsuicide (Breault, 1986) and the presenceor absence of religious denominationmay be more useful than the evaluationof an association between specific religiousdenominations and suicidal behaviors(Dervic, Oquendo, Grunebaum et al.,2004; Faria, Victora, Meneghel et al.,2006).

Regardless of denomination, actualchurch attendance can be used as anindirect indicator of religious commitmentand, in turn, can be considered protectiveagainst suicide (Breault, 1986; Kelleher,Chambers, Corcoran et al., 1998). Church,mosque or other important religiousattendance (i.e., how often someoneattends religious meetings) is one of themost commonly used questions to investi-gate the level of religious involvement(Koenig, 2005; Moreira-Almeida, Neto,& Koenig, 2006). Several studies have

revealed that religious commitment,expressed in church attendance, is closelyinversely associated with suicidal behaviors(da Silva, de Oliveira, Botega et al., 2006;Duberstein, Conwell, Conner et al., 2004;Musick, House, & Williams, 2004; Siegrist,1996; Stack & Lester, 1991). However,exactly which elements of religious partici-pation reduce the risk of suicide cannot bediscerned. Pescosolido and Georgianna(1989) claimed that either religious or othernetwork ties have both integrative andregulative aspects and act therefore asimportant sources of social and emotionalsupport. Another study showed thatvisiting or talking with friends or relativesdid not reduce the likelihood of suicide,but frequent participation in religiousactivities did, which suggests that some-thing more specifically intrinsic in religiousidentity might be responsible for decreasingsuicide risk (Nisbet, Duberstein, Conwellet al., 2000).

A question widely used to investigatethe level of religious involvement, and theimportance of religion in someone’s life,is subjective religiosity (Moreira-Almeida,Neto, & Koenig, 2006). In postmodernsocieties, personal beliefs are at least asrelevant as integration in religious institu-tions when explaining individual and groupbehaviors (Neeleman, 1998; Stack, 1983).The dimension of subjective religiosityleads us closer to the concept of spiritu-ality, which has been described as lessformal and organized and more subjective,individual and inwardly directed than religi-osity (Koenig, McCullough, & Larson,2001). Spirituality outside the formal religi-on has found to start to flourish in thepostmodern era (Hay, 2002).

The aim of the current study was toinvestigate whether religiosity assessed inthese dimensions—religious denomination,organizational religiosity, and subjectivereligiosity—could serve as a protectivefactor against attempted suicide from across-cultural perspective.

M. Sisask et al.

ARCHIVES OF SUICIDE RESEARCH 45


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METHOD

General Description

In 2000, the World Health Organization(WHO) launched the worldwide interventionstudy on suicidal behavior SUPRE-MISS(Suicide Prevention—Multisite InterventionStudy on Suicidal Behaviors) with the mainobjective being to reduce the mortalityand morbidity associated with suicidalbehaviors. The methodology of SUPRE-MISS was elaborated by a WHO expertgroup and adapted to the local conditionsof each participating site (WHO, 2002).

The study was conducted in sevenculturally diverse low- and middle-incomecountries around the world: Brazil(Campinas), Estonia (Tallinn), India(Chennai), Islamic Republic of Iran (Karaj),South Africa (Durban), Sri Lanka(Colombo), Vietnam (Hanoi). The researchprotocol was approved by the relevantethics committee in each site. The detaileddescription of the study and the character-istics of the suicide attempters as well as thecommunity survey have been previouslypresented elsewhere (Bertolote, Fleisch-mann, De Leo et al., 2005; Fleischmann,Bertolote, De Leo et al., 2005).

Data Collection

In each of the participating sites,between 2002 and 2004, medical staffidentified suicide attempters in one ormore emergency settings within a catch-ment area that had a population of atleast 250,000. Once medically stable,the suicide attempters were asked to fillin a consent form and were thereafterinterviewed by clinically experiencedand specially trained psychiatrists, medi-cal doctors, psychologists or psychiatricnurses.

In the same catchment areas, atleast 500 randomly selected communitymembers from the general populationwere interviewed for the communitysurvey. These community members alsoserved as controls for the suicideattempters. All participants providedinformed consent. The interviewerswere specially trained nurses, psycholo-gists, medical students, medical doctors,family health workers, and public healthprofessionals.

In total, 2819 suicide attempters and5484 controls were interviewed. Detailednumbers of the research subjects by partici-pating sites are given in Table 1.

TABLE 1. Number of Suicide Attempters and Control Group Included in the Study

Control group

Suicide attempters Non-suicidal Suicidal� Total

Brazil 162 420 96 516

Estonia 332 433 67 500

India 680 486 14 500

Islamic Republic of Iran 632 433 71 504

South Africa 570 371 129 500

Sri Lanka 300 632 52 684

Vietnam 143 2079 201 2280

Total 2819 4854 630 5484

Note. �Suicidal–persons reporting suicidal behavior (attempts, plans, thoughts) during theirlifetime.

Religiosity Against Attempted Suicide

46 VOLUME 14 � NUMBER 1 � 2010


100

Instruments

The questionnaire for suicide attemp-ters, based on the European parasuicidestudy interview schedule (EPSIS) of theWHO=EURO multicenter study onsuicidal behavior, and a common surveyinstrument for the community survey weredeveloped, translated and pilot-tested ineach site (Kerkhof, Bernasco, Bille-Braheet al., 1999; WHO, 2002).

Both the suicide attempters andcontrols were asked the following religion-related questions:

1. What is your religious denomination?Response choices were: none; Prot-estant; Catholic; Jewish; Muslim; Hindu;Greek orthodox; Buddhist; other.

2. How often do you go to church (orother place of worship)? Responsechoices were: At least once a week; oncea month; 2–3 times a year; about once ayear; almost never.

3. Do you consider yourself to be areligious person? Response choiceswere: no; yes.

To assess suicidal behavior duringtheir life-time, the controls were asked thefollowing questions:

1. Have you ever seriously thought aboutcommitting suicide?

2. Have you ever made a plan for commit-ting suicide?

3. Have you ever attempted suicide?

If the answer was yes to any of thesequestions, a control was classified as suici-dal and excluded from logistic regressionanalysis as improper for the control group(Table 1).

A recurring problem in sociologicalwork is the confounding effect of severalcharacteristics, which may act as buffers,provide protection against attemptedsuicide and adjust thereby the effect of

religiosity less significant (Stack, 2000). Inthe current study, the following socio-demographic control variables were avail-able within the SUPRE-MISS instruments.These included in the regression analysisto statistically control them:

1. Age in years2. Gender: males and females3. Marital status: living with partner

(recoded from: married or living withpermanent partner) and living withoutpartner (recoded from: single; widowed;divorced= separated)

4. Employment status: economically active(recoded from: full-time employed;part-time employed; employed, but onsick leave; temporary work) andeconomically inactive (recoded from:unemployed; armed service; full-timestudent; disabled, permanently sick;retired; housewife=homemaker)

5. Educational status: high educationalstatus (recoded from: secondary edu-cation; non-university higher education;university education) and low edu-cational status (recoded from: none;primary education).

Statistical Analysis

Statistical analysis was performed withthe SPSS program (version 14.0). Differ-ences between suicide attempters and thecontrol group were evaluated by chi-squaretests. For logistic regression analysis, thereligious denomination was recoded to‘‘no’’ and ‘‘yes’’ (for any denomination)answers; frequency of going to churchwas recoded to ‘‘never’’; ‘‘weekly’’;‘‘monthly’’; and ‘‘yearly’’; and for subjectivereligiosity, the original values ‘‘no’’ and‘‘yes’’ were used. Binary and multinomiallogistic regression analyses were performedto calculate odds ratios (OR) with a95% confidence interval (95% CI). Socio-demographic variables (age, gender, marriage,

M. Sisask et al.



101

TABLE2.ReligiousDenomination:SuicideAttempters

(SA)in

ComparisonwithControlGroup(C

G)

None

Protestantism

Catholicism

Jewish

Islam

Hinduism

Orthodox

Buddhism

Other

Total

Brazil

CG

N42

100

344

00

00

228

516

%8.1

19.4

66.7

00

00

0.4

5.4

100

SA

N23

47

75

00

10

08

154

%14.9

30.5

48.7

00

0.6

00

5.2

100

Estonia

CG

N243

58

21

32

0127

143

498

%48.8

11.6

4.2

0.6

0.4

025.5

0.2

8.6

100

SA

N223

33

60

00

65

14

332

%67.2

9.9

1.8

00

019.6

0.3

1.2

100

India

CG

N0

016

023

460

00

1500

%0

03.2

04.6

92.0

00

0.2

100

SA

N1

24

44

025

571

01

14

680

%0.1

3.5

6.5

03.7

84.0

00.1

2.1

100

IslamicRepublic

ofIran

CG

N0

00

0502

00

02

504

%0

00

099.6

00

00.4

100

SA

N0

00

0632

00

00

632

%0

00

0100

00

00

100

South

Africa

CG

N83

81

68

113

62

10

188

497

%16.7

16.3

13.7

0.2

2.6

12.5

0.2

037.8

100

SA

N24

31

74

028

114

01

293

565

%4.2

5.5

13.1

05.0

20.2

00.2

51.9

100

SriLanka

CG

N1

384

0161

116

0291

7663

%0.2

0.5

12.7

024.3

17.5

043.9

1.1

100

SA

N0

254

138

31

0171

3300

%0

0.7

18.0

0.3

12.7

10.3

057.0

1100

Vietnam

CG

N2074

16

40

13

20

2128

22277

%91.1

0.7

1.8

0.6

0.1

00.1

5.6

0.1

100

SA

N134

01

00

00

90

144

%93.1

00.7

00

00

6.3

0100



102

employment, education) were included inthe regression analysis to statisticallycontrol them. The level of statistical signifi-cance was set at a¼ 0.05.

RESULTS

Religious Denomination

The results of the study revealed a largediversity of religious denominations acrossparticipating sites. Predominant religionswere Catholicism and Protestantism inBrazil; Protestantism and Orthodox, inaddition to a great amount of people with-out religious denomination, in Estonia;Hinduism in India; Islam (Shi’ite) in theIslamic Republic of Iran; various denomi-nations without any of them prevailing inSouth Africa; and Buddhism in Sri Lanka.In Vietnam, most of the people reportedno religious denomination (Table 2). Dif-ferences between suicide attempters andthe control group in the pattern of distri-bution of religious denominations were sig-nificant at p< 0.001 level in Estonia, India,Sri Lanka, Brazil and South Africa. The dif-ferences were non-significant in the IslamicRepublic of Iran (p¼ 0.197), where in bothgroups the main religious denominationwas Islam, and in Vietnam (p¼ 0.859),where in both groups the majority ofpeople had no religious denomination.

In total, males and females tended tohave similar patterns of distribution withtwo exceptions only—there were no sig-nificant differences between the suicideattempters and the control groups amongfemales in India (p¼ 0.067) and amongmales in Brazil (p¼ 0.852).

Effect of Religious Denomination,Organizational Religiosity, and Subjective

Religiosity

In India, Sri Lanka and the IslamicRepublic of Iran all controls and=or suicide

attempters had some kind of religiousdenomination, therefore the odds ratiowas not calculable. Religious denominationwas more likely to be reported by the con-trols than the suicide attempters in Estoniaand less likely to be reported in SouthAfrica. In Brazil and Vietnam, the effectof religious denomination was statisticallynon-significant (Table 3).

The frequency of attending church oranother place of worship (organizationalreligiosity) demonstrated a distinctlyprotective effect in Brazil and Iran; yet inSouth Africa and Sri Lanka, the odds ratioswere statistically non-significant. InEstonia, only monthly visits served as aprotective factor while weekly and yearlyvisits were statistically non-significant.However, in India and Vietnam yearlyvisits had a protective effect and weeklyor monthly visits remained statistically non-significant. Controversial results came fromVietnam as weekly visits were statisticallynon-significant, monthly visits demon-strated risk effect and yearly visits a protec-tive effect (Table 4).

TABLE 3. Religious Denomination�: SuicideAttempters in Comparison withControl Group, Binary LogisticRegression Analysis Adjustedfor Gender, Age, Marriage,Employment and Education

95% CI

OR Lower Higher p-value

Brazil 0.71 0.37 1.36 0.299

Estonia 0.51 0.37 0.72 <0.001

India Not calculable

Islamic

Republic

of Iran

Not calculable

South Africa 5.86 3.15 10.90 <0.001

Sri Lanka Not calculable

Vietnam 0.72 0.21 2.53 0.612

Note. �Religious denomination – yes (any) versusnone.

M. Sisask et al.



103

In Brazil, Estonia, the Islamic Republicof Iran and Sri Lanka, controls were morelikely to consider themselves to be religious

(subjective religiosity) compared withsuicide attempters; in South Africa, con-trols were less likely to consider themselvesreligious. In India and Vietnam, the oddsratio of subjective religiosity was statisti-cally non-significant (Table 5).

DISCUSSION

The aim of this study was to find outwhether different dimensions of religiosity—religious denomination, organizational religi-osity, and subjective religiosity—could serveas possible protective factors against attemptedsuicide.

Suicidal behaviors are a global publichealth problem and a complex phenom-enon influenced by a number of mixedbiological, psychological, social and culturalfactors. Among other agents, religious con-text has been recognized as a major culturalfactor in the determination of suicidalbehaviors (Bertolote & Fleischmann, 2002;Stack, 2000). To the best of our knowledge,the present study is the first individual-level

TABLE 5. Subjective Religiosity�, SuicideAttempters in Comparison withControl Group, Binary LogisticRegression Analysis Adjustedfor Gender, Age, Marriage,Employment and Education

95% CI


Brazil 0.17 0.10 0.29 <0.001

Estonia 0.54 0.37 0.77 0.001

India 0.79 0.50 1.24 0.305

Islamic

Republic

of Iran

0.60 0.44 0.82 0.002

South Africa 2.71 1.90 3.86 <0.001

Sri Lanka 0.36 0.17 0.75 0.007

Vietnam 1.00 0.56 1.81 0.989

Note. �Subjective religiosity – considering him=her-self as religious person.

TABLE 4. Organizational Religiosity�, SuicideAttempters in Comparison withControl Group, MultinominalLogistic Regression Analysis��

adjusted for Gender, Age, Marriage,Employment and Education

95% CI


Brazil

Weekly 0.33 0.19 0.60 <0.001

Monthly 0.25 0.12 0.51 <0.001

Yearly 0.30 0.15 0.62 0.001

Estonia

Weekly 0.97 0.37 2.54 0.958

Monthly 0.23 0.09 0.60 0.003

Yearly 0.87 0.62 1.24 0.450

India

Weekly 0.67 0.41 1.10 0.111

Monthly 0.83 0.45 1.51 0.533

Yearly 0.45 0.26 0.77 0.003

Islamic

Republic

of Iran

Weekly 0.50 0.33 0.77 0.001

Monthly 0.53 0.35 0.79 0.002

Yearly 0.46 0.33 0.65 <0.001

South Africa

Weekly 0.93 0.60 1.42 0.723

Monthly 0.85 0.51 1.42 0.526

Yearly 0.94 0.53 1.66 0.824

Sri Lanka

Weekly 0.67 0.32 1.39 0.276

Monthly 1.64 0.78 3.46 0.190

Yearly 1.85 0.80 4.28 0.148

Vietnam

Weekly 0.67 0.13 3.33 0.620

Monthly 1.12 0.56 2.22 0.753

Yearly 0.28 0.15 0.52 <0.001

Note. �Organizational religiosity – frequency of goingto church or other place of worship.��Reference category—never.




104

study conducted concurrently in culturallydifferent sites, which enables the effect ofreligiosity on suicide attempts to be investi-gated from a cross-cultural perspective.However, the results of the study cannotbe interpreted without keeping in mindthe reliability of self-reported informationabout sensitive issues, the complexity ofsuicidal behaviors and the knowledge thatreligiosity is not the only, all-powerfulfactor associated with suicidality. Moreover,both religion and suicidal behaviors aresocial constructs and consequently dynamicacross eras and cultures.

In most known religions of the world,suicide is condemned; especially in thethree monotheistic religions of Judaism,Christianity and Islam. However, thestrength of this condemnation has variedover time and within the religions them-selves. Within Christianity, the conservativechurch members (Catholic and Orthodox)have been the most outspoken againstsuicide with the sixth commandment(‘‘Thou shall not kill’’) used as the officialChristian statement prohibiting suicide(Kelleher, Chambers, Corcoran et al.,1998; Pescosolido & Georgianna, 1989).Both Hindus and Buddhists are moreambivalent in their attitudes towards suici-dal behaviors. They believe in karma, whichfacilitates the idea that putting an end toone’s life is not the final step (Bolz,2002). The Hindu religion tolerates suicidein situations when a person is consideredsocially dead already, such as serious handi-cap (Tousignant, Seshadri, & Raj, 1998).Islam is arguably much firmer about thesinfulness of suicide than Hinduism andBuddhism, and even Christianity (Lester,2006). The Islamic doctrine regardingsuicide is well known: persons taking theirown life will be denied entry to heaven. Sui-cide is considered a sin and subsequently acrime, but it is also a shameful act withinthe family and subsequently must be con-cealed (Khan & Reza, 2000). Still, the Islamreligion condemns on one hand and

forgives on the other, as suicide victimsare often seen as mentally ill (Simpson &Conklin, 1988). A separate social constructknown in the context of Islam is suicideterrorism, as suicide terrorists do notappear to be truly suicidal and belong toa subgroup of terrorist population(Townsend, 2007).

The prevailing religious denominationsacross the SUPRE-MISS sites differed to alarge extent and most of the major religionsin the world were represented. The sitesdiffered substantially across the religiosity-secularity spectrum. Some sites were veryreligious (India, the Islamic Republic ofIran, Sri Lanka) and some were very orrather secular (Vietnam, Estonia). Braziland South Africa were more ambivalentin their religiosity. In India, the IslamicRepublic of Iran and Sri Lanka, the effectof religious denomination on suicideattempts was not calculable, as both con-trols and suicide attempters reported somekind of religious denomination. In a verysecular country, such as Vietnam, religiousdenomination had no effect againstattempted suicide. A protective effectemerged only in Estonia which is rathersecular but still a predominantly Christiancountry.

In Brazil, the other Christian country,Catholicism was more frequent amongthe control group than among suicideattempters and Protestantism was morefrequent among suicide attempters thanamong controls. Subsequently, religiousdenomination had no effect on suicideattempts in Brazil but it can be assumedthat Protestantism could neutralize the pro-tective effect of Catholicism. However, thisis only a speculation. This study analyzedChristianity as a whole as differentiatingthe effect of denominations within Chris-tianity was not the issue of interest. How-ever, a study by Botega and colleagues(2005) found that in Brazil, the lifetimeprevalence of suicidal ideation among Pro-testants was lower than among Catholics.

M. Sisask et al.



105

South Africa, the most pluralisticcountry, was the only site where religiousdenomination showed a risk effect. SouthAfrica has been described as ‘‘The RainbowNation’’ because of its cultural diversity.There are a variety of ethnic groups and agreater variety of cultures within each ofthese groups. While cultural diversity is seenas a national asset, the interaction of culturesresults in the blurring of cultural norms andboundaries at the individual, family and cul-tural group levels (Wassenaar, van der Veen,& Pillay, 1998). Subsequently, there is a largediversity of religious denominations and thisdoes not seem favorable in terms of provid-ing protection against attempted suicide.There is a study available which demon-strates that religious homogeneity, whichincreases social interaction and social bondsbetween individuals with shared culturalvalues, is inversely associated with suiciderate (Ellison, Burr, & McCall, 1997).

Religious denomination is one of themost widely used measures of religion inmedical research. However, it is a formalconstruct for an individual and does notmeasure the extent of social interaction orother characteristics of social support andis even less informative in terms of intra-personal or psychological perspectives(Flannelly, Ellison, & Strock, 2004).

The frequency of attending churchor other place of worship in differentSUPRE-MISS sites gave controversialresults. In the predominantly ChristianBrazil and the Islamic Republic of Iran,the frequency of church attendance pro-vided an unequivocal protective effectagainst attempted suicide. No effect oforganizational religiosity on suicideattempts was detected in Sri Lanka andSouth Africa, the two most heterogeneoussites of religious denomination. Somewhatconfusing results on organizational religi-osity came from Estonia, India and Viet-nam. To interpret these results, themeaning of going to church and, evenmore specifically, the meaning of the fre-

quency of church attendance within differ-ent cultures needs further explanation.

Subjective religiosity is very informaland a deeply subjective psychological con-struct. It may mediate health outcomesthrough engendering feelings of self-esteem,self-worth and positive emotions thus pro-viding a sense of meaning, fostering feelingsof control and the ability to manage diffi-culties (Flannelly, Ellison, & Strock, 2004).In our postmodern world, subjective religi-osity seems to be the crucial dimension ofreligiosity. The controls within the SUPRE-MISS study were more likely to report sub-jective religiosity than suicide attempters infour sites out of seven (Brazil, Estonia, theIslamic Republic of Iran and Sri Lanka). Intwo sites (India and Vietnam), the effectwas statistically non-significant. It is knownfrom previous research that, in India, sub-jective religiosity protects against completedsuicide, not against attempted suicide(Vijayakumar, 2003). The results from Viet-nam can be attributed to its secularity, whichmay influence the overall way of thinkingand mentality. In South Africa, the riskeffect of subjective religiosity was an excep-tional result again, as was also true for theeffect of religious denomination. As men-tioned above, this can be explained by thecultural diversity, heterogeneity and blurringof cultural norms within the site.

In conclusion, according to the resultsof the current study, individual-level asso-ciations between different dimensions ofreligiosity and attempting suicide exist.Nevertheless, these associations variedbetween dimensions of religiosity andacross cultures. In particular, subjectivereligiosity (considering him=herself to bea religious person) may serve as a protec-tive factor against non-fatal suicidalbehaviors in some cultures.

Limitations

The SUPRE-MISS study was notspecifically designed to study the effects




106

of religion on suicidal behaviors, thereforeno specifically designed scales wereincluded in the questionnaire. The infor-mation regarding religiosity was collectedfrom investigated subjects by asking directquestions. Even with clinically experiencedand specially trained interviewers, thepossibility remains that the self-reportedinformation could be incomplete due torespondents’ memory bias and unwilling-ness to report honestly on sensitive issueslike religiosity. Measuring religion with asingle question is a general limitation ofstudies in which religion is a minor or inci-dental variable, rather than the primaryfocus (Flannelly, Ellison, & Strock, 2004).

Another limitation is that religiosityhas other aspects which were not assessedby the SUPRE-MISS instrument. Theseother dimensions of religiosity, as well asspirituality, may also play an important rolein some cultures. Moreover, religiosity isnot the only factor which has an effect onattempted suicide. In the current study, theeffect of the main socio-demographic vari-ables (age, gender, marriage, employment,education) was statistically controlled and,even with other confounders, the indirecteffects of religion are important. It can helpto understand what factors influence healthbehaviors, social support and this knowledgecan have valuable intellectual and practicalimplications, for example influencing publichealth (Flannelly, Ellison, & Strock, 2004).

AUTHOR NOTE

This paper is based on the data andexperience obtained during the authors’participation in the WHO MultisiteIntervention Study on Suicidal Behaviors(SUPRE-MISS), a project funded by theWorld Health Organization and the partici-pating field research centers.

The collaborating investigators in thisstudy have been (in alphabetical order):Dr. Damani De Silva, Colombo; Prof. Van

Tuong Nguyen, Hanoi; Prof. LourensSchlebusch, Durban; Prof. Diego De Leo,Brisbane has acted as scientific advisorfor the WHO SUPRE-MISS study.

The Tallinn center obtained additionalfunding from the following agencies: theEstonian Health Insurance Fund; NationalPrevention of Suicide and MentalIll-Health (NASP) at Karolinska Instituteand Stockholm County Council’s Centrefor Suicide Research and Prevention; theEstonian Scientific Foundation (ProjectNo. 7132).

Thanks are due to Maimu Nommikand Kathy McKay for their thoroughlinguistic and stylistic revision of themanuscript.

Merike Sisask, Estonian-Swedish Men-tal Health and Suicidology Institute (ERSI)and Tallinn University, Tallinn, Estonia.

Airi Varnik, Estonian-Swedish MentalHealth and Suicidology Institute (ERSI)and Tallinn University, Tallinn, Estonia,and National Prevention of Suicide andMental Ill-Health (NASP) at KarolinskaInstitute and Stockholm County Council’sCentre for Suicide Research and Preven-tion; WHO Lead Collaborating Centre ofMental Health Problems and SuicideAcross Europe, Stockholm, Sweden.

Kairi Kolves, Estonian-Swedish Men-tal Health and Suicidology Institute (ERSI),Tallinn, Estonia and Australian Institutefor Suicide Research and Prevention(AISRAP), Brisbane, Australia.

Jose M. Bertolote, Department ofMental Health and Substance Abuse,World Health Organization, Geneva,Switzerland. The author is staff memberof the World Health Organization. Theauthor alone is responsible for the viewsexpressed in this publication and they donot necessarily represent the decisions,policy or views of the World HealthOrganization.

Jafar Bolhari, Tehran PsychiatricInstitute (IUMS), Mental Health ResearchCenter, Tehran, Islamic Republic of Iran.

M. Sisask et al.



107

Neury J. Botega, Department ofPsychiatry, FCM – UNICAMP, Campinas,Brazil.

Alexandra Fleischmann, Department ofMental Health and Substance Abuse, WorldHealth Organization, Geneva, Switzerland.The author is staff member of the WorldHealth Organization. The author alone isresponsible for the views expressed in thispublication and they do not necessarily rep-resent the decisions, policy or views of theWorld Health Organization.

Lakshmi Vijayakumar, Department ofPsychiatry, Voluntary Health Services &SNEHA, Chennai, India.

Danuta Wasserman, National Preven-tion of Suicide and Mental Ill-Health(NASP) at Karolinska Institute and Stock-holm County Council’s Centre for SuicideResearch and Prevention; WHO LeadCollaborating Centre of Mental HealthProblems and Suicide Across Europe,Stockholm, Sweden.

Correspondence concerning this articleshould be addressed to Merike Sisask,Estonian-Swedish Mental Health andSuicidology Institute (ERSI), Oie 39,Tallinn 11615 Estonia. E-mail: [email protected]

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28(1), 50–61.

Townsend, E. (2007). Suicide terrorists: Are they

suicidal? Suicide & Life-Threatening Behavior, 37(1),

35–49.

Wassenaar, D. R., van der Veen, M. B. W., & Pillay,

A. L. (1998). Women in cultural transition:

Suicidal behavior in South African Indian women.

Suicide & Life-Threatening Behavior, 28(1), 82–93.

WHO. (2002). Multisite Intervention Study on

Suicidal Behaviours SUPRE-MISS: Protocol of

SUPRE-MISS.

Vijayakumar, L. (2003). Psychosocial risk factors for

suicide in India. In L. Vijayakumar (Ed.), Suicide pre-

vention: Meeting the challenge together (pp. 149–162).

India: Orient Longman.

Vijayakumar, L., John, S., Pirkis, J., et al. (2005).

Suicide in developing countries (2): Risk factors.

Crisis, 26(3), 112–119.

M. Sisask et al.



APPENDIXES

111

WHO/MSD/MBD/02.1 Page 5

Annex 1 SUPRE-MISS QUESTIONNAIRE

(SUPRE-MISS-Q)

1. IDENTIFICATION OF THE SITE (INTAKE)

2. IDENTIFICATION OF THE PATIENT (INTAKE)

3. PRESENT SUICIDE ATTEMPT (INTAKE)

4. SOCIO-DEMOGRAPHIC INFORMATION

5. CURRENT EPISODE HISTORY

6. PREVIOUS SUICIDE ATTEMPT HISTORY AND FAMILY DATA

7. PHYSICAL HEALTH, CONTACT WITH HEALTH SERVICES, MENTAL HEALTH

8. ALCOHOL AND DRUG RELATED QUESTIONS

9. WHO WELL-BEING INDEX

10. BECK DEPRESSION INVENTORY

11. HOPELESSNESS

12. TRAIT ANGER SCALE

13. SOCIAL SUPPORT

14. LEGAL OR OFFENDING HISTORY / ANTISOCIAL BEHAVIOUR

15. WHO/DAS – PSYCHIATRIC DISABILITY ASSESSMENT SCHEDULE: SOCIAL ROLE PERFORMANCE

Appendix 1 – SUPRE-MISS questionnaire for suicide attempters

112


SUPRE-MISS QUESTIONNAIRE

INSTRUCTIONS FOR THE INTERVIEWER

Please note that INTAKE part 1.-3. have to be filled in by the interviewer and part 4.-15. have to be filled in alternatively by the interviewer in the presence of the interviewee and by the interviewee himself/herself.

PLEASE INSTRUCT THE INTERVIEWEE TO GIVE ONLY ONE ANSWER PER QUESTION!

Please mark the chosen answer with an “X” on the right hand side of each page, or, if requested, fill in numbers or write down the answer.

Rate “888” if information is not available and “999” if item is not applicable.

113


SUPRE-MISS QUESTIONNAIRE (SUPRE-MISS-Q)

1. IDENTIFICATION OF THE SITE (INTAKE)

1.1 Country:

1.2 Service/Hospital:

1.3 Date of admission: Day / Month / Year:

1.4 Time of admission: Hour / Minute:

1.5 Attended by: 1 _ Emergency Department 2 _ Intensive Care Unit 3 _ Other ward, specify: __________

1.6 Who accompanies the patient? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1.7 Date of discharge from hospital: Day / Month / Year: (in case of access to hospital administration files, discharge date can be taken from the files)

1.8 Time of discharge from hospital: Hour / Minute:

2. IDENTIFICATION OF THE PATIENT (INTAKE)

2.1 Patient’s identification number:

2.2 Sex: 1 _ Male 2 _ Female 3 _ Transsexual

2.3 Date of birth: Day / Month / Year:

2.4 Present marital status:

1 _ Single 2 _ Married or living with permanent partner; since when: _ _ Day _ _ Month _ _ _ _ Year 3 _ Widowed; since when: _ _ Day _ _ Month _ _ _ _ Year 4 _ Divorced / separated; since when: _ _ Day _ _ Month _ _ _ _ Year

2.5 Years of education: Years:

2.6 What is the highest completed education the patient has? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) 1 _ None 2 _ Primary education 3 _ Secondary education 4 _ Non-university higher education 5 _ University education 6 _ Other, specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

��_ _ _ _ _ _ _ _ _ _ _

_ _ / _ _ / _ _ _ _

_ _ / _ _

1 2 3

_ _ / _ _ / _ _ _ _

_ _ / _ _

��1 2 3 888 999

_ _ / _ _ / _ _ _ _ 888 999

1 2 3 4 888 999

�� 888 999

1 2 3 4 5 6 888 999

114


2.7 Does the patient currently go to school? 1 _ No 2 _ Yes

2.8a What is the patient’s occupation? If he or she is unemployed or not economically active: What was his or her last occupation? (State if the patient never had a paid job.) (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) Use the patient’s words: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.8b Which of the following occupational categories best describes the patient’s occupation? Choose only one answer according to the patient’s most important occupation.

1 _ Legislator, senior official or manager 2 _ Professional (e.g. science, health, art) 3 _ Technician or associate professional (e.g. inspector, medical assistant) 4 _ Clerk (e.g. secretary) 5 _ Service worker, shop or market sales worker (e.g. waiter, police officer) 6 _ Skilled agricultural and fishery worker 7 _ Craft and related trades worker (e.g. painter, baker, tailor) 8 _ Plant or machine operator or assembler (e.g. driver) 9 _ Elementary occupation (e.g. cleaner, labourer) 10 _ Armed forces 11 _ Other, specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.9 What is the patient’s employment status? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) Choose only one answer according to the patient’s most important activity at the present time.

1 _ Full-time employed (including self-employed) 2 _ Part-time employed (including self-employed) 3 _ Employed, but on sick leave 4 _ Temporary work 5 _ Unemployed; since when: _ _ Day _ _ Month _ _ _ _ Year 6 _ Armed services 7 _ Full-time student 8 _ Disabled, permanently sick; since when: _ _ Day _ _ Month _ _ _ _ Year 9 _ Retired; since when: _ _ Day _ _ Month _ _ _ _ Year 10 _ Housewife/homemaker 11 _ Other, specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3. PRESENT SUICIDE ATTEMPT (INTAKE)

3.1 Date of suicide attempt: Day / Month / Year:

3.2 Day of the week: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.3 Time: Hour / Minute:

3.4 Place: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1 2 888 999

1 2 3 4 5 6 7 8 9 10 11

888 999

1 2 3 4 5 6 7 8 9 10 11

888 999

_ _ / _ _ / _ _ _ _ 888 999

_ _ / _ _ 888 999

115


3.5 Method: _ _ _ _ _ _ _ _ _ _ _ (according to ICD-10 codes, see below):

X60 _ Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics

X61 _ Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified

X62 _ Intentional self-poisoning by and exposure to narcotics and psychodysleptics (hallucinogens), not elsewhere classified

X63 _ Intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system X64 _ Intentional self-poisoning by and exposure to other and unspecified drugs,

medicaments and biological substances X65 _ Intentional self-poisoning by and exposure to alcohol X66 _ Intentional self-poisoning by and exposure to organic solvents and halogenated

hydrocarbons and their vapours X67 _ Intentional self-poisoning by and exposure to other gases and vapours X68 _ Intentional self-poisoning by and exposure to pesticides X69 _ Intentional self-poisoning by and exposure to other and unspecified chemicals

and noxious substances X70 _ Intentional self-harm by hanging, strangulation and suffocation X71 _ Intentional self-harm by drowning and submersion X72 _ Intentional self-harm by handgun discharge X73 _ Intentional self-harm by rifle, shotgun and larger firearm discharge X74 _ Intentional self-harm by other and unspecified firearm discharge X75 _ Intentional self-harm by explosive material X76 _ Intentional self-harm by smoke, fire and flames X77 _ Intentional self-harm steam, hot vapours and hot objects X78 _ Intentional self-harm by sharp object X79 _ Intentional self-harm by blunt object X80 _ Intentional self-harm by jumping from a high place X81 _ Intentional self-harm by jumping or lying before moving object X82 _ Intentional self-harm by crashing of motor vehicle X83 _ Intentional self-harm by other specified means X84 _ Intentional self-harm by unspecified means

3.6 Regarding the physical consequences and the danger to life for the attempted suicide:

0 _ no significant physical harm, no medical treatment required 1 _ medical attention/surgery required, but no danger to life 2 _ medical attention/surgery required, had/has danger to life

3.7 Regarding the type of care:

0 _ After treatment at emergency department patient was discharged 1 _ Patient stayed under observation/treatment in emergency department and was

discharged 2 _ From the emergency department patient was transferred to the intensive care unit or

other clinical or surgical ward/unit 3 _ From emergency department patient was directly transferred to a psychiatric

institution

60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84

888 999

0 1 2 888 999

0 1 2 3 888 999

116


3.8 (If applicable:) Patient was referred to:

0 _ was not referred to any professional service 1 _ was sent to general health care centre (or primary health care) 2 _ was sent to psychiatric outpatient clinic 3 _ was sent to private professional service

3.9 (If applicable:) Offer of professional care:

0 _ Patient accepts to go/come to consultation 1 _ Patient is not sure if he/she will show up or not 2 _ Patient refuses

0 1 2 3 888 999

0 1 2 888 999

117



Please ask the interviewee the following questions and give the following introduction: “In the following, I will ask general questions about your age, living arrangements, work or study, etc. Your answers should reflect your actual situation. Please give only one answer per question and please indicate any question that is unclear to you.” Rate “888” if information is not available and “999” if item is not applicable.


4.1 Where were you born? (country)

4.2 What is your nationality?

4.3 Have you lived with different partners? 1 _No 2 _Yes; 4.3.1 If yes, how many: _ _

4.4 How many times have you been divorced? (Number)

4.5 How many children do or did you have, including children who are adopted? (Do not count children who were born dead.) (Number)

4.6 How many children do you have, who are aged less than 16 years, for whom you have shared or sole responsibility? (Number)

4.7 With whom do you live presently (at the time you were admitted to the hospital)? (Household composition at time of suicide attempt).

1 _ Living alone 2 _ Living alone with child(ren) 3 _ Living with partner without child(ren) 4 _ Living with partner and child(ren) 5 _ Living with parents 6 _ Living with other relatives / friends 7 _ Living in jail 8 _ Living in psychiatric institution 9 _ Living in homes/institutions 10 _ Other, specify: __________

4.8 During the past year, with whom did you live most of the time? (What was the usual situation?) (Household composition during past year, usual situation).

1 _ Living alone 2 _ Living alone with child(ren) 3 _ Living with partner without child(ren) 4 _ Living with partner and child(ren) 5 _ Living with parents 6 _ Living with other relatives / friends 7 _ Living in jail 8 _ Living in psychiatric institution 9 _ Living in homes/institutions 10 _ Other, specify: __________

_ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _

1 2 888 999

�� 888 999

�� 888 999

�� 888 999

1 2 3 4 5 6 7 8 9 10 888 999

1 2 3 4 5 6 7 8 9 10 888 999

118


4.9 Area of residence at time of the suicide attempt: (area or postal code)

4.10 Do you live in a rural or urban residence area? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!)

1 _ Rural 2 _ Urban

4.11 During the past year (that is: between now and one year ago), have you been unemployed for some time? With unemployed I mean that you were looking for a job but could not find one. If yes, how long in total have you been unemployed during the past year? (Fill in zero, if patient has not been unemployed.) Weeks:

4.12 What was your annual income in the last year (after tax)? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4.13a What is or was the occupation of your father?

Use your own words: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4.13b Which of the following occupational categories best describes your father’s occupation? Choose only one answer according to your father’s most important occupation.


��

1 2 888 999

_ _ Weeks

1 2 3 4 5 6 7 8 9 10 11

888 999

119


4.14 What is your religious denomination? 1 _ None 2 _ Protestant 3 _ Catholic 4 _ Jewish 5 _ Muslim 6 _ Hindu 7 _ Greek orthodox 8 _ Buddhist 9 _ Other, specify _ _ _ _ _ _ _ _ _ _ _

4.15 How often do you go to church (or other place of worship)? 1 _ At least once a week 2 _ Once a month 3 _ 2-3 times a year 4 _ About once a year 5 _ Almost never

4.16 Why? What is your motive? (Use the patient’s words) _ _ __ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4.17 Do you consider yourself to be a religious person? 1 _ No 2 _ Yes

4.18 What is your preferred sexual orientation? 1 _ Heterosexual 2 _ Homosexual 3 _ Bisexual 4 _ Uncertain 5 _ Refused to answer


Please ask the interviewee the following questions and give the following introduction: “After the general questions, let us talk about the things that happened just before your admission to the hospital. Please think back to what happened. Please listen to all answers carefully and then give only one answer per question. Please indicate any question that is unclear to you.”


5. CURRENT EPISODE HISTORY

5.1 Was anybody near you when you tried to harm yourself? (e.g. in the same room, telephone conversation.)

0 _ Somebody present 1 _ Somebody nearby or in contact (e.g. telephone) 2 _ No one nearby or in contact

1 2 3 4 5 6 7 8 9 888 999

1 2 3 4 5 888 999

1 2 888 999

1 2 3 4 5 888 999

0 1 2 888 999

120


5.2 At the moment you did it? Were you expecting someone? Could someone soon arrive? Did you know that you had some time before anyone could arrive? Or didn’t you think about the possibility?

0 _ Timed so that intervention is probable 1 _ Timed so that intervention is not likely 2 _ Timed so that intervention is highly unlikely 3 _ You did not think about it

5.3 Did you do anything to prevent someone finding you? (e.g. disconnect the telephone, put a note on the door, etc.)

0 _ No precautions at all 1 _ Passive precautions, such as avoiding others but doing nothing to prevent their

intervention (e.g. being alone in room with unlocked door) 2 _ Active precautions (e.g. being alone in room with locked door)

5.4 Around the time you harmed yourself, did you call someone to tell what you just did?

0 _ Notified potential helper regarding attempt 1 _ Contacted but did not specifically notify potential helper regarding attempt 2 _ Did not contact or notify potential helper

5.5 Did you do anything, such as paying bills, say goodbye, write a testament, once you decided to harm yourself?

0 _ None 1 _ You thought about making or made some arrangements in anticipation of death 2 _ Definite plans made (making up or changing a will, giving gifts, taking out insurance)

5.6 Had you planned the attempt for some time? Did you make any preparations such as saving pills, etc.?

0 _ No preparation (no plan) 1 _ Minimal or moderate preparation 2 _ Extensive preparation (detailed plan)

5.7 Did you write one or more farewell letters? If yes, to whom? If no, did you think about writing one?

0 _ Neither written a note, nor thought about writing one 1 _ Thought about writing one 2 _ Note written (present or torn up)

5.8 Did you tell neighbours, friends and/or family members, implicitly or explicitly, that you had the intention to harm yourself?

0 _ None 1 _ Equivocal communication (ambiguous or implied) 2 _ Unequivocal communication (explicit)

5.9 What were your feelings towards life and death? Did you want to live more strongly than you wanted to die? Didn’t you care whether to live or to die?

0 _ You did not want to die 1 _ You did not care whether you lived or died 2 _ You wanted to die

0 1 2 3 888 999

0 1 2 888 999

0 1 2 888 999

0 1 2 888 999

0 1 2 888 999

0 1 2 888 999

0 1 2 888 999

0 1 2 888 999

121


5.10 Can you tell me what you hoped to accomplish by harming yourself?

0 _ Mainly to manipulate others 1 _ Temporary rest 2 _ Death 3 _ Other, specify: _ _ _ _ _ _ _ _ _ _ _

5.11 What did you think were the chances that you would die as a result of your act?

0 _ You thought that death was unlikely or did not think about it 1 _ You thought that death was possible but not probable 2 _ You thought that death was probable or certain 3 _ Other, specify: _ _ _ _ _ _ _ _ _ _ _

5.12 Relation between alcohol/drug use (specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _) and current suicide attempt:

0 _ none/some previous ingestion, but without relation to the suicide attempt 1 _ sufficient for the deterioration of judicious capacity and responsibility 2 _ intentional intake to facilitate and implement the suicide attempt

OPTIONAL 5.13 In your opinion, what was the main reason why you harmed yourself? Why did you do this?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

INSTRUCTIONS FOR INTERVIEWER

Please ask the interviewee the following questions and give the following introduction: “In the following, let us see if you have ever before deliberately poisoned or injured yourself, or if a family member has ever before done so.” Rate “888” if information is not available and “999” if item is not applicable.

6. PREVIOUS SUICIDE ATTEMPT HISTORY AND FAMILY DATA

6.1 Previous suicide attempt(s)? 1 _ No 2 _ Yes

6.1.1 If yes, how many? (Number)

6.1.2 When was the last one? Day / Month / Year:

6.2 If yes, method of previous suicide attempt (see ICD-10 codes in 3.5):

Previous suicide attempt number: 1. 2. 3. 4. 5. Please fill in the corresponding code: _ _ _ _ _ _ _ _ _ _

6.3 Suicide of closest people (parents, friend, boy-/girlfriend) = “model”: 1 _ No 2 _ Yes

6.4 If no, skip sub-questions and go to question 6.5.

If yes, specify the person (=”model), the method of the “model” event (see ICD-10 codes in 3.5), and the time lapse between “model” event and present suicide attempt.

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 888 999

1 2 888 999

�� 888 999

_ _ / _ _ / _ _ _ _ 888 999

1 2 888 999

122


6.4.1a “Model” number 1: specify who?

1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ boy-/girlfriend 6 _ friend 7 _ other, specify _ _ _ _ _ _ _ _ _

6.4.1b “Model number 1: method (please fill in corresponding code, see 3.5) _ _ _ _ _ _

6.4.1c “Model” number 1: time lapse:

1 _ less than 1 day ago 2 _ less than 1 week ago 3 _ less than 1 month ago 4 _ less than 3 months ago 5 _ less than 12 months ago 6 _ 12 months or more ago

6.4.2a “Model” number 2: who? 1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ boy-/girlfriend 6 _ friend 7 _ other, specify _ _ _ _ _ _ _ _ _


6.4.2c “Model” number 2: time lapse: 1 _ less than 1 day ago 2 _ less than 1 week ago 3 _ less than 1 month ago 4 _ less than 3 months ago 5 _ less than 12 months ago 6 _ 12 months or more ago

6.4.3a “Model” number 3: who?




1 _ less than 1 day ago 2 _ less than 1 week ago 3 _ less than 1 month ago 4 _ less than 3 months ago 5 _ less than 12 months ago

6 _ 12 months or more ago

1 2 3 4 5 6 7 888 999

_ _ 888 999

1 2 3 4 5 6 888 999

1 2 3 4 5 6 7 888 999

_ _ 888 999

1 2 3 4 5 6 888 999

1 2 3 4 5 6 7 888 999

_ _ 888 999

1 2 3 4 5 6 888 999

123












6.5 I would like to know how then, after the last time you poisoned/harmed yourself, your relatives and friends reacted to what you had done. I will mention some possible reactions, and I would like you to indicate whether such a reaction was shown by no one of your family and friends, by some of them, or by all of them.

6.5.1 They felt pity for you 1 _ No one 2 _ One person 3 _ Some people 6.5.2 They showed understanding 1 _ No one 2 _ One person 3 _ Some people 6.5.3 They showed anger or irritation 1 _ No one 2 _ One person 3 _ Some people 6.5.4 They felt embarrassed,

tried to avoid you 1 _ No one 2 _ One person 3 _ Some people 6.5.5 They felt uncertain 1 _ No one 2 _ One person 3 _ Some people 6.5.6 They laughed at you 1 _ No one 2 _ One person 3 _ Some people 6.5.7 They ignored the attempt 1 _ No one 2 _ One person 3 _ Some people

1 2 3 4 5 6 7 888 999

_ _ 888 999

1 2 3 4 5 6 888 999

1 2 3 4 5 6 7 888 999

_ _ 888 999

1 2 3 4 5 6 888 999

1 2 3 888 999 1 2 3 888 999 1 2 3 888 999

1 2 3 888 999 1 2 3 888 999 1 2 3 888 999 1 2 3 888 999

124


6.6 I would also like to know how you felt, after the previous time you poisoned/harmed yourself. I will again mention some possible feelings, and I would like you to say whether that applied to you. Please think back to how you felt one week after the previous time you poisoned/harmed yourself.

6.6.1 Did you feel good? 1 _ No 2 _ Yes 6.6.2 Did you feel released? 1 _ No 2 _ Yes 6.6.3 Proud because you managed to carry it through? 1 _ No 2 _ Yes 6.6.4 Did you feel pity about yourself? 1 _ No 2 _ Yes 6.6.5 Did you feel angry about yourself? 1 _ No 2 _ Yes 6.6.6 Did you feel afraid of yourself? 1 _ No 2 _ Yes 6.6.7 Did you feel uncertain of yourself? 1 _ No 2 _ Yes 6.6.8 Did you feel ashamed of yourself? 1 _ No 2 _ Yes 6.6.9 Did you feel uncertain towards others? 1 _ No 2 _ Yes 6.6.10 Did you feel embarrassed? 1 _ No 2 _ Yes

6.7 Have any of the following members of your biological family (i.e. related by birth only) died by suicide or made a suicide attempt?

6.7.1. Died by suicide:

6.7.1.1 Parent 1_No 2_Yes 6.7.1.2 Brother or sister 1_No 2_Yes 6.7.1.3 Child 1_No 2_Yes 6.7.1.4 Grandparent 1_No 2_Yes

6.7.2. Made a suicide attempt:


1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

125



Please ask the interviewee the following questions and give the following introduction: “Some people are affected by traumatic experiences in their lives. Have you ever experienced any of the following events?”

6.8 Have you ever suffered any persecution, violence, prejudice or hardship because of any of the following? 6.8.1 Your race 1_No 2_Yes 6.8.2 Your religious beliefs 1_No 2_Yes 6.8.3 Your political beliefs 1_No 2_Yes 6.8.4 A physical handicap or disability 1_No 2_Yes 6.8.5 Your sexual orientation 1_No 2_Yes

6.9 Were you ever threatened with abuse by someone? 1_No 2_Yes

6.10 Were you ever emotionally abused? 1_No 2_Yes

6.11 Were you ever beaten so badly you had to see (or should have seen) a doctor? 1_No 2_Yes

6.12 Have you ever been physically or psychologically forced by anyone to engage in any unwanted sexual activity, sexually assaulted or raped? 1_No 2_Yes

6.13 Were you ever the victim of a disaster, accident or war which affected your ability to live as before? 1_No 2_Yes

6.14 Were you ever the witness of a disaster, accident or war which affected your ability to live as before? 1_No 2_Yes

6.15 Were you ever a prisoner of war? 1_No 2_Yes

6.16 Were you ever physically tortured? 1_No 2_Yes

6.17 Were you ever emotionally or psychologically tortured? 1_No 2_Yes


Please ask the interviewee the following questions and give the following introduction: “In the following, I will ask general questions about your health.”



7.1 Height in cm:

7.2 Weight in kg:

7.3 Do you have any longstanding physical illness or disability that has troubled you for at least one year?

1 _ No 2 _ Yes

7.3.1 If yes, what is the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7.3.2 How long have you had this? 555 _ from birth on _ _ (Years)

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

_ _ _ _ _ _ 888 999

_ _ _ _ _ _ 888 999

1 2 888 999

555 _ _ 888 999

126


7.4 I would like you to think about the two weeks before you were admitted to the hospital. During these two weeks, did you have to cut down on any of the things you usually do because of physical illness or injury?

1 _ No 2 _ Yes

7.4.1 If yes, what was the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7.5 Over the last three months, would you say your physical health on the whole has been excellent, good, fair, or poor? 1 _ Excellent 2 _ Good 3 _ Fair 4 _ Poor

Contact with health services:

General practitioner

7.6 How many times did you see a general practitioner or family doctor, or specialists during the last year? (excludes dentist, psychiatrist)

1 _ not at all 2 _ one time 3 _ 2-3 times 4 _ 4 or more times

7.7 Could you give the approximate dates of the last time you contacted a doctor before you poisoned/harmed yourself? Why did you contact him/her, what were your complaints? Did the doctor prescribe any medicines?

7.7.1 Date of last contact (before suicide attempt): Day / Month / Year:

7.7.2 Reason: 1 _ physical 2 _ psychological 3 _ both physical and psychological

7.7.3 Medicines prescribed: 1 _ No 2 _ Yes, specify: __________

7.7.4 If medicines prescribed, ask: Did you use any of the medicines prescribed in that contact for self-poisoning (did you deliberately overdose)? 1 _ No 2 _ Yes

7.8 At the time of your last contact with the doctor, did you have thoughts about poisoning or injuring yourself? 1 _ No 2 _ To some extent 3 _ Yes, definitely

7.8.1 If “To some extent” (2_) or “Yes, definitely” (3_), ask: Did you talk to the doctor about these thoughts? (Maybe you vaguely referred to such plans) 1 _ No 2 _ Vaguely referred to 3 _ Yes

1 2 888 999

1 2 3 4 888 999

1 2 3 4 888 999

_ _ / _ _ / _ _ _ _ 888 999

1 2 3 888 999

1 2 888 999

1 2 888 999

1 2 3 888 999

1 2 3 888 999

127


In-patient psychiatric treatment (includes treatment on psychiatric ward of general hospital)

7.9 How many times, if ever, have you been treated in a psychiatric hospital, in a psychiatric ward of a general hospital, or in any other in-patient institution for people with mental problems? (Be sure that the patient refers to in-patient treatment: “you were in the hospital both night and day”. In-patient treatment after the present suicide attempt not included.)

1 _ Never 2 _ 1 time 3 _ 2-3 times 4 _ 4 times or more

If “Never” (1_), continue with: Out-patient psychiatric treatment and day care.

7.10 If one or more times in-patient treatment: Could you, as accurately as possible and for each admission separately describe: when you were admitted, how long you stayed there, and for which reasons you were admitted? (Start with last admission. If patient was in in-patient psychiatric treatment at the time of the suicide attempt, start facts on this treatment. Do not code admissions after present suicide attempt.)

Admission: Length of stay: Reason for admission: Month/Year Months

1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Out-patient psychiatric treatment and day care

7.11 Have you ever been in contact with one of the following professional services for treatment or advice? (TO BE FILLED IN ACCORDING TO NATIONAL SITUATION, codes should include treatment by private psychiatrist; an example (based on health services in the Netherlands) is given below for reference.)

(EXAMPLE)

7.11.1 Psychiatric service, polyclinic service 1 _ No 2 _ Yes 7.11.2 Psychiatric service, day-care 1 _ No 2 _ Yes 7.11.3 Community Mental Health Care 1 _ No 2 _ Yes 7.11.4 Private psychologist or psychiatrist 1 _ No 2 _ Yes 7.11.5 Consultation service for alcohol and drug related problems 1 _ No 2 _ Yes 7.11.6 Consultation service for relational and sexual problems 1 _ No 2 _ Yes

7.12 Other intervention for emotional problems

Have you ever received assistance for emotional problems from anyone else? For instance self-help groups like Alcoholics Anonymous, S.O.S. telephone services, etc. ? 1_No 2_Yes; Specify: _ _ _ _ _ _ _ _ _ _

1 2 3 4 888 999

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999

128


7.13 This question only, if respondent has treatment:

Did the treatment you received have any influence on you poisoning/injuring yourself last week?

1 _ no influence 2 _ some influence 3 _ decisive influence

7.14 Do you or did you ever experience for prolonged periods of time (for over at least on year) troubles within yourself that hindered your functioning? (Make this question clearer, if needed, by examples like: fears of places, anxiety to leave your house, excessive fear of people in general, depressive feelings, other emotions or thoughts that influenced you repeatedly like obsessions, e.g., to be compelled to clean yourself or your house, etc.).

1 _ No 2 _ Yes

7.14.1 If yes, what was the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


7.15 Did you have any psycho-social difficulties during the last year with _ _ _ _ _ _ ? Specify how long ago:

7.15.1 With your partner (fights, infidelity, separation, alcohol, death): 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.15.2 With your family (father, mother, siblings, others): 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.15.3 Work/studies (dissatisfaction, unemployment, reproof, conflicts): 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.15.4 Serious financial problems (housing, hunger, default of payment, etc.): 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.15.5 Disability or serious physical illness: 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.15.6 Pregnancy (unwanted?), recent provoked abortion: 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.15.7 Problems with police, justice: 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.15.8 Others: which? _ _ _ _ _ _ _ _ _ _ 1 _No 2 _1 month 3 _6 months 4 _1 year ago

7.16 Now I would like you to think about the two weeks before you were admitted to the hospital. During these two weeks, did you have to cut down on any of the things you usually do because of feelings or thoughts or any other troubles like the ones I mentioned just before (like fears of places, depressive feelings, obsessions or compulsions, or any other psychological condition)? (Please note that it concerns afflictions which must severely hinder normal functioning.)

1 _ No 2 _ Yes

7.16.1 If yes, what was the matter with you? _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _

1 2 3 888 999

1 2 888 999

555 _ _ 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 888 999

129


7.17 How satisfied are you with your life? (from “1” = dissatisfied to “5” = satisfied) 7.17.1 Now 1 2 3 4 5 7.17.2 30 days ago 1 2 3 4 5 7.17.3 One year ago 1 2 3 4 5 7.17.4 Five years ago 1 2 3 4 5

7.18 How satisfied with your life do you think you will be? (from “1” = dissatisfied to “5” = satisfied) 7.18.1 30 Days from now 1 2 3 4 5 7.18.2 One year from now 1 2 3 4 5 7.18.3 Five years from now 1 2 3 4 5

7.19 Did you have the opportunity to talk about your problems (ask for help) with any relatives during the last month?

1 _ No 2 _ Yes

7.19.1 If yes, with whom?

1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ other relative, specify _ _ _ _ _ _ _ _ _ _

7.20 Did you have the opportunity to talk about your problems (ask for help) with anyone outside your family during the last month?

1 _ No 2 _ Yes

7.20.1 If yes, with whom?

1 _ boy-/girlfriend 2 _ friend 3 _ colleague 4 _ neighbour 5 _ health professional 6 _ other, specify _ _ _ _ _ _ _ _ _ _

7.21 Did you take any psychopharmacologic drugs during the last month?

1 _ No 2 _ Yes 7.21.1 If yes, which one(s)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7.22 Do you receive psychological/psychiatric treatment currently?

1 _ No 2 _ Yes

1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999

1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999

1 2 888 999

1 2 3 4 5 888 999

1 2 888 999

1 2 3 4 5 6 888 999

1 2 888 999

1 2 888 999

130


7.23 Psychological exam

“0” = absent “1” = light “2” = moderate “3” = marked “4” = severe

7.23.1 Psycho-motor slowdown 0 1 2 3 4 7.23.2 Distrustful, defensive 0 1 2 3 4 7.23.3 Histrionic 0 1 2 3 4 7.23.4 Depressive mood 0 1 2 3 4 7.23.5 Anxious, tense, uneasy 0 1 2 3 4 7.23.6 Euphoria, excited mood 0 1 2 3 4 7.23.7 Incongruent, flattened emotions 0 1 2 3 4 7.23.8 Delirium, misinterpretations 0 1 2 3 4 7.23.9 Thought disturbance 0 1 2 3 4 7.23.10 Hallucinations 0 1 2 3 4 7.23.11 Diminished intelligence 0 1 2 3 4 7.23.12 Excessive preoccupation with

physical functions 0 1 2 3 4 7.23.13 Suicidal ideation 0 1 2 3 4

7.24 Psychiatric diagnosis, according to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (preferably ICD-10; if DSM-IV, only axis I diagnosis required.)

1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7.25 Psychiatric diagnosis made by (name of the person): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7.26 Date of psychiatric diagnosis: Day / Month / Year:

7.27 Time of psychiatric diagnosis: Hour / Minute:

7.28 Former psychiatric diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7.29 Somatic diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7.30 Type of prescribed medicines: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999

0 1 2 3 4 888 999 0 1 2 3 4 888 999

_ _ / _ _ / _ _ _ _ 888 999

_ _ / _ _ 888 999

131



Please ask the interviewee the following questions and give the following introduction: “I would like to continue with some questions related to alcohol and drugs.” Rate “888” if information is not available and “999” if item is not applicable.


8.1 In your life, which of the following substances have you ever used?

8.1.1 Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 1 _ No 2 _ Yes 8.1.2 Alcoholic beverages (beer, wine, liquor, etc.) 1 _ No 2 _ Yes 8.1.3 Marijuana (pot, grass, hash, etc.) 1 _ No 2 _ Yes 8.1.4 Cocaine or Crack 1 _ No 2 _ Yes 8.1.5 Stimulants or Amphetamines (speed, diet pills, ecstasy, etc.) 1 _ No 2 _ Yes 8.1.6 Inhalants (nitrous, glue, spray paint, gasoline, paint thinner) 1 _ No 2 _ Yes 8.1.7 Sedatives or Sleeping Pills (Valium, Librium, Xanax, Haldol,

Seconal, Quaaludes, etc.) 1 _ No 2 _ Yes 8.1.8 Hallucinogens (LSD, acid, mushrooms, PDP, Special K, etc.) 1 _ No 2 _ Yes 8.1.9 Heroin, Morphine, Methadone or Pain Medication (codeine,

Dilaudid, Darvon, Demoral, Percodan, Fiorional, etc.) 1 _ No 2 _ Yes 8.1.10 Other, specify _ _ _ _ _ _ _ _ _ _ 1 _ No 2 _ Yes

Probe if all answers are negative and ask: Not even when you were in school?

8.2 If yes to any of these items, in the past three months, how often have you used the substances you mentioned?

8.2.1 Tobacco products (cigarettes, chewing tobacco, cigars, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.2 Alcoholic beverages (beer, wine, liquor, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.3 Marijuana (pot, grass, hash, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.4 Cocaine or Crack? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.5 Stimulants or Amphetamines (speed, diet pills, ecstasy, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.6 Inhalants (nitrous, glue, spray paint, gasoline, paint thinner)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.7 Sedatives or Sleeping Pills (Valium, Librium, Xanax, Haldol, Seconal, Quaaludes, etc.)?

1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.8 Hallucinogens (LSD, acid, mushrooms, PDP, Special K, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

8.2.9 Heroin, Morphine, Methadone or Pain Medication (codeine, Dilaudid, Darvon, Demoral, Percodan, Fiorional, etc.)?


8.2.10 Other, specify _ _ _ _ _ _ _ _ _ _ 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999 1 2 888 999

1 2 888 999 1 2 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

132


8.3 When was the last time you had a drink containing alcohol?

1 _hour ago 2 _days ago 3 _months ago

8.4 How many standard drinks* did you have on that occasion? _ _ number of drinks

8.4.1 How many standard drinks* of beer did you have on that occasion? _ _ number of drinks

8.4.2 How many standard drinks* of wine did you have on that occasion? _ _ number of drinks

8.4.3 How many standard drinks* of spirits did you have on that occasion? _ _ number of drinks

8.4.4 How many standard drinks* of other (please specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) did you have on that occasion? _ _ number of drinks

* 330 ml of regular beer (can, bottle, glass), 120 ml of wine, 40 ml of whisky/liquor. TO BE ADAPTED TO LOCAL CODING CATEGORIES (One standard drink contains 10g of pure alcohol. Usually a regular beer contains 4-5% alcohol, wine 12% and spirits 40%. The ethanol content is calculated as: Amount in ml x percentage of alcohol in the beverage x ethanol conversion factor (1ml ethanol=0.79g): Example: 330ml beer x 0.04 x 0.79 = approximately 10g pure alcohol.)

8.5 In the past year (= past 12 months), how often did you have a drink containing alcohol?

1 _ Never 6 _ 1-2 times a month 2 _ 1-3 times in the past year 7 _ 3-4 times a month 3 _ 4-6 times in the past year 8 _ 1-2 times a week 4 _ 7-9 times in the past year 9 _ 3-4 times a week 5 _ 10-12 times in the past year 10 _ 5-6 times a week

11 _ Daily or more often

8.6 On those days when you drank, how many drinks did you usually have? _ _ drinks (Record exact number of drinks, all types of beverages together)

8.7 How often in the past year did you drink more than 4 (for females) / 5 (for males) drinks* in one occasion?

1 _ Never 6 _ 1-2 times a month 2 _ 1-3 times in the past year 7 _ 3-4 times a month 3 _ 4-6 times in the past year 8 _ 1-2 times a week 4 _ 7-9 times in the past year 9 _ 3-4 times a week 5 _ 10-12 times in the past year 10 _ 5-6 times a week

11 _ Daily or more often

* TO BE ADAPTED TO LOCAL BINGE/HIGH RISK DRINKING CATEGORIES

1 2 3 888 999

_ _ 888 999

_ _ 888 999

_ _ 888 999

_ _ 888 999

_ _ 888 999

1 2 3 4 5 6 7 8 9 10 11

888 999

1 2 3 4 5 6 7 8 9 10 11

888 999

133



At this time, please hand the questionnaire to the interviewee for the parts 9.-13.

The chosen answer has to be marked with an “X”.


Please take back the questionnaire for the parts 14. and 15. and enter the answers.

Please stay with the interviewee all along and offer to clarify any questions that may arise.

134


INSTRUCTIONS FOR THE INTERVIEWEE

In the following, you will find questions regarding various aspects of your life, e.g., your well-being or social issues.

Please read both the questions and the answers you can choose from carefully and answer what comes to your mind first. Try not to stay with one question too long.

PLEASE GIVE ONLY ONE ANSWER PER QUESTION!

Please mark the chosen answer with an “X”, for example “3 X” or “X Yes”, or, if requested, fill in numbers or write down the answer. Please mark the chosen answer directly after the corresponding question.

Mark “888” if information is not available and “999” if item is not applicable.

In case you have any questions or in case anything is unclear to you, please do not hesitate to ask the interviewer.

If you do not have any questions at this time, please start filling in the questionnaire.

9. WHO WELL-BEING INDEX

Instruction: “Please indicate for each of the following statements which is closest to how you have been feeling over the last two weeks. Only make one indication per statement. Notice that higher numbers mean better well-being.”

“5” = All of the time “4” = Most of the time “3” = More than half of the time “2” = Less than half of the time “1” = Some of the time “0” = At no time

9.1 I have felt cheerful and in good spirits 5 _ 4 _ 3 _ 2 _ 1 _ 0 _

9.2 I have felt calm and relaxed 5 _ 4 _ 3 _ 2 _ 1 _ 0 _

9.3 I have felt active and vigorous 5 _ 4 _ 3 _ 2 _ 1 _ 0 _

9.4 I have felt fresh and rested 5 _ 4 _ 3 _ 2 _ 1 _ 0 _

9.5 My daily life has been filled with things that interest me 5 _ 4 _ 3 _ 2 _ 1 _ 0 _

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

135


10. BECK DEPRESSION INVENTORY

Instruction: “Below you will find groups of statements. Please read each group of statements carefully. Then pick out the one statement in each group which best represents the way you feel right now. Be sure to read all statements in each group before making your choice.”

10.1 0 _ I do not feel sad. 1 _ I feel sad. 2 _ I am sad all the time and I can’t snap out of it. 3 _ I am so sad or unhappy that I can’t stand it.

10.2 0 _ I am not particularly discouraged about the future. 1 _ I feel discouraged about the future. 2 _ I feel I have nothing to look forward to. 3 _ I feel that the future is hopeless and that things cannot improve.

10.3 0 _ I do not feel like a failure. 1 _ I feel I have failed more than the average person. 2 _ As I look back on my life, all I can see is a lot of failures. 3 _ I feel I am a complete failure as a person.

10.4 0 _ I get as much satisfaction out of things as I used to. 1 _ I don’t enjoy things the way I used to. 2 _ I don’t get real satisfaction out of anything anymore. 3 _ I am dissatisfied or bored with everything.

10.5 0 _ I don’t feel particularly guilty. 1 _ I feel guilty a good part of the time. 2 _ I feel quite guilty most of the time. 3 _ I feel guilty all of the time.

10.6 0 _ I don’t feel I am being punished. 1 _ I feel I may be punished. 2 _ I expect to be punished. 3 _ I feel I am being punished.

10.7 0 _ I don’t feel disappointed in myself. 1 _ I am disappointed in myself. 2 _ I am disgusted with myself. 3 _ I hate myself.

10.8 0 _ I don’t feel I am any worse than any body else.1 _ I am critical of myself for my weaknesses or mistakes. 2 _ I blame myself all the time for my faults. 3 _ I blame myself for everything bad that happens.

10.9 0 _ I don’t have any thoughts of killing myself. 1 _ I have thoughts of killing myself, but I would not carry them out. 2 _ I would like to kill myself. 3 _ I would kill myself if I had the chance.

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

136


10.10 0 _ I don’t cry any more than usual. 1 _ I cry more now than I used to. 2 _ I cry all the time now. 3 _ I used to be able to cry, but now I can’t cry even though I want to.

10.11 0 _ I am no more irritated now than I ever am. 1 _ I get annoyed or irritated more easily than I used to. 2 _ I feel irritated all the time now. 3 _ I don’t get irritated at all by the things that used to irritate me.

10.12 0 _ I have not lost interest in other people. 1 _ I am less interested in other people than I used to be. 2 _ I have lost most of my interest in other people. 3 _ I have lost all of my interest in other people.

10.13 0 _ I make decisions about as well as I ever did. 1 _ I put off making decisions more than I used to.2 _ I have greater difficulty in making decisions than before. 3 _ I can’t make decisions at all anymore.

10.14 0 _ I don’t feel I look any worse than I used to. 1 _ I am worried that I am looking old or unattractive. 2 _ I feel that there are permanent changes in my appearance that make me look

unattractive. 3 _ I believe I look ugly.

10.15 0 _ I can work as well as before. 1 _ It takes an extra effort to get started at doing something. 2 _ I have to push myself very hard to do anything.3 _ I can’t do any work at all.

10.16 0 _ I can sleep as well as usual. 1 _ I don’t sleep as well as I used to. 2 _ I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 3 _ I wake up several hours earlier than I used to and cannot get back to sleep.

10.17 0 _ I don’t get more tired than usual. 1 _ I get tired more easily than I used to. 2 _ I get tired from doing almost anything. 3 _ I am too tired to do anything.

10.18 0 _ My appetite is no worse than usual. 1 _ My appetite is not as good as it used to be. 2 _ My appetite is much worse now. 3 _ I have no appetite at all anymore.

10.19 0 _ I haven’t lost much weight, if any lately. 1 _ I have lost more than 5 pounds. 2 _ I have lost more than 10 pounds. 3 _ I have lost more than 15 pounds.

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

0 1 2 3 888 999

137


10.20 I am purposely trying to lose weight by eating less. 0 _ No 1 _ Yes

10.21 0 _ I am no more worried about my health than usual. 1 _ I am worried about physical problems such as aches and pains; or upset stomach; or

constipation. 2 _ I am very worried about physical problems and it’s hard to think of much else. 3 _ I am so worried about physical problems, that I cannot think about anything else.

10.22 0 _ I have not noticed any recent change in my interest in sex. 1 _ I am less interested in sex than I used to be. 2 _ I am much less interested in sex now. 3 _ I have lost interest in sex completely.

11. HOPELESSNESS

Instruction: “Below, there is one statement regarding your future. Please mark the option which reflects best the way you feel at the present time.”

11.1 My future seems dark to me. 1 _ False 2 _ True

12. TRAIT ANGER SCALE

Instruction: “The following questions deal with feelings of anger. Please indicate for each statement whether it applies to you in general (how you generally feel). Mark only one answer that represents best how you generally feel.

“1” = Almost never “2” = Sometimes “3” = Often “4” = Almost always

12.1 I have a fiery temper. 1 2 3 4

12.2 I am quick-tempered. 1 2 3 4

12.3 I am a hot headed person. 1 2 3 4

12.4 It makes me furious when I am always criticized in front of others. 1 2 3 4

12.5 I get angry when I’m slowed down by others’ mistakes. 1 2 3 4

12.6 I feel infuriated when I do a good job and get poor evaluation. 1 2 3 4

12.7 I fly off the handle. 1 2 3 4

12.8 I feel annoyed when I am not given recognition for doing good work. 1 2 3 4

12.9 When I get mad, I say nasty things. 1 2 3 4

12.10 When I get frustrated, I feel like hitting someone. 1 2 3 4

0 1 888 999

0 1 2 3 888 999

0 1 2 3 888 999

1 2 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

1 2 3 4 888 999

138


13. SOCIAL SUPPORT

Instruction: “The following part deals with the question of giving and getting support from or to family and friends. Two kinds of support are distinguished: - Practical support refers to support concerning daily activities such as looking after your house when you are away, looking after your children, pets or flowers, looking after you or doing the shopping when you are ill, etc. It also includes financial support. - Moral support refers to emotional support when minor or major problems arise. It includes that people are available to share worries with, to talk about personal problems, etc. Please read each question carefully. Please indicate in the “family” row the one answer that applies best to how you feel about it and then indicate in the “friends” row the one answer that applies best to how you feel about it.

“0” = No, not at all “1” = To some extent “2” = Yes, very much

WHETHER YOU NEED SUPPORT FROM 13.1 Do you feel that you need practical support? 13.1.1 Family: 0 1 2 13.1.2 Friends: 0 1 2

13.2 Do you feel that you need moral support from? 13.2.1 Family: 0 1 2

13.2.2 Friends: 0 1 2

WHETHER YOU GET SUPPORT FROM 13.3 Do you feel that you get the practical support you need?

13.3.1 Family: 0 1 2 13.3.2 Friends: 0 1 2

13.4 Do you feel that you get the moral support you need? 13.4.1 Family: 0 1 2

13.4.2 Friends: 0 1 2

WHETHER YOU ARE NEEDED FOR SUPPORT BY 13.5 Do you feel that you are needed for practical support?

13.5.1 Family: 0 1 2 13.5.2 Friends: 0 1 2

13.6 Do you feel that you are needed for moral support? 13.6.1 Family: 0 1 2

13.6.2 Friends: 0 1 2

WHETHER YOU GIVE SUPPORT TO 13.7 Do you feel that you give the practical support that is needed from you?

13.8.1 Family: 0 1 2 13.8.2 Friends: 0 1 2

13.8 Do you feel that you give the moral support that is needed from you? 13.8.1 Family: 0 1 2 13.8.2 Friends: 0 1 2

Instruction:

Please hand the questionnaire back to the interviewer at this point.

0 1 2 888 999 0 1 2 888 999

0 1 2 888 999 0 1 2 888 999

0 1 2 888 999 0 1 2 888 999

0 1 2 888 999 0 1 2 888 999

0 1 2 888 999 0 1 2 888 999

0 1 2 888 999 0 1 2 888 999

0 1 2 888 999 0 1 2 888 999

0 1 2 888 999 0 1 2 888 999

139



Please take the questionnaire back from the interviewee.

Please ask the interviewee the following questions and give the following introduction: “I would like to continue with some questions on legal matters.”


14. LEGAL OR OFFENDING HISTORY / ANTISOCIAL BEHAVIOUR

14.1 Have you done any of the following during the past five years?

14.1.1 boycott 1 _No 2 _Yes 14.1.2 occupation of buildings and sit-ins 1 _No 2 _Yes 14.1.3 blocking traffic 1 _No 2 _Yes 14.1.4 personal violence 1 _No 2 _Yes 14.1.5 damage to property 1 _No 2 _Yes 14.1.6 violent demonstration 1 _No 2 _Yes

14.2 Have you ever been convicted of a criminal offence (excluding traffic offences)? 1 _ No 2 _ Yes

14.3 If yes; specify: 1 _ once 2 _ 2-3 times 3 _ several times

14.4 If yes, specify the date of the most recent conviction: Day / Month / Year:

14.5 If yes, what was the major reason for the most recent conviction?

14.5.1 Property offences 1 _No 2 _Yes 14.5.2 Violent offences 1 _No 2 _Yes 14.5.3 Political or administrative crimes 1 _No 2 _Yes 14.5.4 Substance use 1 _No 2 _Yes 14.5.5 Sexual offences 1 _No 2 _Yes 14.5.6 Other: (specify) _ _ _ _ _ _ _ _ _ 1 _No 2 _Yes

14.6 Have you ever been to prison (for other than traffic reasons)? 1 _ No 2 _ Yes

14.7 If yes, specify: 1 _ once 2 _ 2-3 times

3 _ several times

14.8 If yes, specify the date of the most recent imprisonment: Day / Month / Year:

14.9 If yes, what was the major reason for the most recent imprisonment?

14.9.1 Property offences 1 _No 2 _Yes 14.9.2 Violent offences 1 _No 2 _Yes 14.9.3 Political or administrative crimes 1 _No 2 _Yes 14.9.4 Substance use 1 _No 2 _Yes 14.9.5 Sexual offences 1 _No 2 _Yes 14.9.6 Other: (specify) _ _ _ _ _ _ _ _ _ 1 _No 2 _Yes

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999

1 2 3 888 999

_ _ / _ _ / _ _ _ _ 888 999

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999

1 2 3 888 999

_ _ / _ _ / _ _ _ _ 888 999

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

140



In the following part, please inquire about the issues (i, ii, …) listed for each question and then indicate the rating for each question.

Please give the following introduction: “I would like to finish with some questions regarding your everyday life.”


15. SOCIAL ROLE PERFORMANCE (SECTION 2 OF WHO/DAS – PSYCHIATRIC DISABILITY ASSESSMENT SCHEDULE)

“0”= no dysfunction “1” = minimum dysfuction “2” = obvious dysfunction “3” = serious dysfunction “4” = very serious dysfunction “5” = maximum dysfunction

15.1 Participation in household activities during past month

Inquire about: (i) patient’s participation in common activities of the household, such as having meals together, doing domestic chores, going out or visiting together, playing games, watching television, etc.; (ii) patient’s participation in decision-making concerning the household, e.g. decisions about the children, money, etc. For housewives, consider the household jobs that a housewife usually has to do. Make a rating without regard to whether patient is asked to participate, left on his/her own or rejected in some way.

15.2 Marital role: affective relationship to spouse during past month (Here “spouse” means a steady partner regardless of legal status)

Inquire about: (i) patient’s communication with spouse (e.g. talking to spouse about ordinary events, news, the children, etc.) (ii) patient’s ability to show affection and warmth towards spouse (occasional outbursts of anger or irritability should be evaluated against the cultural norm) (iii) spouse’s feeling that patient is a source of support to whom spouse can turn. Ask for examples.

15.3 Marital role: sexual relations with spouse during past month

Consider: (i) occurrence of sexual intercourse in past month (ii) whether patient experiences sexual relations as satisfactory (iii) whether spouse experiences sexual relationships as satisfactory

15.4 Parental role: interest and care of child (children) during past month

Consider: (i) undertaking and performance of child care tasks appropriate to patient’s position in household (e.g. feeding, putting to bed, taking to school – for small children; looking after child’s needs – for older children); (ii) interest in child (e.g. playing, reading to, taking interest in his/her problems, school work, etc.). If children are not living with patient, consider and rate only (ii).

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

141


15.5 Sexual role: relationships with persons other than marital partner during past month (unmarried patient or patient not living with spouse)

Consider: (i) heterosexual (or homosexual) interests and emotional responsiveness shown by patient; (ii) actual relationship or contacts sought by patient (regardless) of whether sexual relations involved or not).

15.6 Social contacts: friction in interpersonal relationships outside the household in past month

Consider: Overt conflictive behaviour on the part of the patient involving inappropriate arguments, annoyance, anger or marked irritability arising in social situations outside own home, e.g. (i) with supervisors, colleagues, customers, etc., if patient is working; (ii) with neighbours, other people in the community etc., if patient is a housewife or not working; (iii) with teachers, administrators, other students etc., if patient is a student. For patients living in hostels or other communal accommodation, include frictions arising with other boarders.

15.7 Occupational role: work performance during past month (including students and persons in sheltered employment)

Inquire about: (i) whether patient conforms to the work routine – going to work regularly and on time, observing the rules, etc.; (ii) quality of performance and output. Household work is excluded (rate in question 1.). If key informant is unable to provide information, make a rating after consulting alternative sources.

15.8 Occupational role: interest in getting a job or in going back to work or studies

(To be rated for patients of employable age but currently not employed or not working, students are included. If the patient is a housewife, use judgement about local expectations concerning housewife’s seeking employment outside the home.) Consider: (i) interest in obtaining or returning to a job or studies; (ii) actual steps undertaken to get a job or start studies.

15.9 Interests and information during the past month

Consider: (i) interest shown by patient in local or world events or in other matters, as commensurate with his/her social background, education, and level of intelligence; (ii) efforts to obtain such information.

15.10 Patient’s behaviour in emergencies or in out-of-the-ordinary situations that have occurred in the past six months

Consider: Patient’s response to events, such as: (i) sickness or accident affecting a family member;(ii) sickness, accident or incident involving other people; (iii) minor emergencies (e.g. breakdown of equipment); (iv) any other situation out of the routine for the patient, normally requiring action (e.g. patient left to baby-sit, requested to pass on a message, etc.)

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

0 1 2 3 4 5 888 999

142


Annex 2 SUPRE-MISS COMMUNITY SURVEY


The questionnaire comprises questions regarding socio-demographic information, the history of suicide attempt, family data, physical health, contact with health services, mental health, alcohol and drug related items, and community stress and problems.

Please ask the interviewee to mark the chosen answer with an “X” directly after the question or read both the questions and the eligible answers to the interviewee and mark the chosen answer. Mark “888” if information is not available and “999”, if item is not applicable.

Please enter the subject’s identification number, the country and the site in the questionnaire at the beginning (see 0.1 to 0.3 on the first page).

Appendix 2 – SUPRE-MISS community survey questionnaire

143


SUPRE-MISS COMMUNITY SURVEY

0.1 Identification number: _ _

0.2 Country: _ _ _ _ _ _ _ _ _ _

0.3 Site: _ _ _ _ _ _ _ _ _ _

INSTRUCTIONS FOR THE INTERVIEWEE

In the following, you will find questions regarding yourself, your family, the community you live in, and your physical and mental health.

Please read the questions carefully and answer what comes to your mind first. Try not to stay with one question too long.

PLEASE GIVE ONLY ONE ANSWER PER QUESTION!

Please mark an “X” on the “_” next to the answer you choose, for example “X Yes” or “3 X”, or, if requested, fill in numbers or write down the answer. Please mark the chosen answer directly after the corresponding question. Mark “888” if information is not available and “999” if item is not applicable. In case you have any questions or in case anything is unclear to you, please do not hesitate to ask the interviewer.

Thank you for participating in the survey and if you do not have any questions at this time, please start filling in the questionnaire.


1.1 Sex: 1 _ Male 2 _ Female 3 _ Transsexual

1.2 Date of birth: _ _ Day _ _ Month _ _ _ _ Year

1.3 Where were you born? (country) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1.4 What is your nationality? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1.5 Present marital status: 1 _ Single 2 _ Married or living with permanent partner; since when: _ _ Day _ _ Month _ _ _ _ Year 3 _ Widowed; since when: _ _ Day _ _ Month _ _ _ _ Year 4 _ Divorced / separated; since when _ _ Day _ _ Month _ _ _ _ Year

1.6 Have you lived with different partners? 1 _ No 2 _ Yes, how many: _ _

1.7 How many times have you been divorced? (Number) _ _

1.8 How many children do or did you have, including children who are adopted? (Do not count children who were born dead.) (Number) _ _

1.9 How many children do you have, who are aged less than 16 years, for whom you have shared or sole responsibility? (Number) _ _

1 2 3 888 999

_ _ / _ _ / _ _ _ _ 888 999

1 2 3 4 888 999

1 2 888 999

�� 888 999

�� 888 999

�� 888 999

144


1.10 With whom do you live presently (household composition) 1 _ Living alone 2 _ Living alone with child(ren) 3 _ Living with partner without child(ren) 4 _ Living with partner and child(ren) 5 _ Living with parents 6 _ Living with other relatives / friends 7 _ Living in jail 8 _ Living in psychiatric institution 9 _ Living in homes/institutions 10 _ Other, specify: _ _ _ _ _ _ _ _ _ _ _

1.11 Do you live in a rural or urban residence area? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!)

1 _ Rural 2 _ Urban

1.12 Years of education: _ _ Years

1.13 What is the highest completed education you have? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) 1 _ None 2 _ Primary education 3 _ Secondary education 4 _ Non-university higher education 5_ University education 6 _ Other; specify: _ _ _ _ _ _ _ _ _ _

1.14a What is your occupation? If you are unemployed or not economically active: What was your last occupation? (State if you never had a paid job.) (TO BE ADAPTED TO LOCAL CODING CATEGORIES!)

Use your own words: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1.14b Which of the following occupational categories best describes your occupation? Choose only one answer according to your most important occupation.


1 2 3 4 5 6 7 8 9 10

888 999

1 2 888 999

�� 888 999

1 2 3 4 5 6 888 999

1 2 3 4 5 6 7 8 9 10 11

888 999

145


1.15 What is your employment status? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) Choose only one answer according to the most important activity for you at the present time.

1 _ Full-time employed (including self-employed) 2 _ Part-time employed (including self-employed) 3 _ Employed, but on sick leave 4 _ Temporary work 5 _ Unemployed; since when: _ _ Day _ _ Month _ _ _ _ Year 6 _ Armed services 7 _ Full-time student 8 _ Disabled, permanently sick; since when: _ _ Day _ _ Month _ _ _ _ Year 9 _ Retired; since when: _ _ Day _ _ Month _ _ _ _ Year 10 _ Housewife/homemaker 11 _ Other, specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1.16 During the past year (that is: between now and one year ago), have you been unemployed for some time? With unemployed I mean that you were looking for a job but could not find one. If yes, how long in total have you been unemployed during the past year? (Fill in zero, if you have not been unemployed.) (Weeks)

_ _ Weeks

1.17 What was your annual income in the last year (after tax)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ (TO BE ADAPTED TO LOCAL CODING CATEGORIES!)

1.18 What is your religious denomination? 1 _ None 2 _ Protestant 3 _ Catholic 4 _ Jewish 5 _ Muslim 6 _ Hindu 7 _ Greek orthodox 8 _ Buddhist 9 _ Other, specify _ _ _ _ _ _ _ _ _ _ _ _ _

1.19 How often do you go to church (or other place of worship)? 1 _ At least once a week 2 _ Once a month 3 _ 2-3 times a year 4 _ About once a year 5 _ Almost never

1.20 Why? What is your motive? (Use your own words) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1.21 Do you consider yourself being a religious person? 1 _ No 2 _ Yes

1.22 What is your preferred sexual orientation? 1 _ Heterosexual 2 _ Homosexual 3 _ Bisexual 4 _ Uncertain 5 _ Refused to answer

1 2 3 4 5 6 7 8 9 10 11

888 999

_ _ 888 999

_ _ _ _ _ _ 888 999

1 2 3 4 5 6 7 8 9

888 999

1 2 3 4 5 888 999

1 2 888 999

1 2 3 4 5 888 999

146


2. SUICIDE ATTEMPT HISTORY AND FAMILY DATA

2.1 Have you ever seriously thought about committing suicide? 1_ No 2_ Yes

If answer is no, skip sub-questions and go to question 2.2.

2.1.1 How old were you the first time this happened? _ _ years old

2.1.2 Did this happen to you at all in the last twelve months? 1_ No 2_ Yes

2.1.3 How old were you the last time this happened to you? _ _ years old

2.2 Have you ever made a plan for committing suicide? 1_ No 2_ Yes



2.2.2 Did this happen to you at all in the last twelve months? 1_ No 2_ Yes


2.3 Have you ever attempted suicide? 1_ No 2_ Yes


2.3.1 How many times ever in your lifetime have you attempted suicide? (Number of times) _ _



2.3.4 Did you make a suicide attempt at all in the last twelve months? 1_ No 2_ Yes

2.3.5 Thinking about the first time you ever attempted suicide, which of these statements best describes the situation?

1 _ I made a serious attempt to kill myself and it was only luck that I did not succeed.

2 _ I tried to kill myself but knew that the method was not fool-proof. 3 _ My attempt was a cry for help. I did not intend to die. 4 _ Don’t know.

2.3.6 What was the method of this first suicide attempt (How did you try to kill yourself)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.3.7 Did this first suicide attempt result in an injury or poisoning? 1_No 2_Yes 3_Don’t know

2.3.8 Did this first suicide attempt require medical attention? 1_No 2_Yes 3_Don’t know

2.3.9 Did this first suicide attempt require hospital admission for one night or longer? 1_No 2_Yes 3_Don’t know

1 2 888 999

�� 888 999

1 2 888 999

�� 888 999

1 2 888 999

�� 888 999

1 2 888 999

�� 888 999

1 2 888 999

�� 888 999

�� 888 999

�� 888 999

1 2 888 999

1 2 3 4 888 999

1 2 3 888 999

1 2 3 888 999

1 2 3 888 999

147


2.3.10 Thinking about the last (most recent) time you attempted suicide, which of these statements best describes the situation?

1 _ I made a serious attempt to kill myself and it was only luck that I did not succeed.

2 _ I tried to kill myself but knew that the method was not fool-proof. 3 _ My attempt was a cry for help. I did not intend to die. 4 _ Don’t know.

2.3.11 What was the method of this last suicide attempt (How did you try to kill yourself)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.3.12 Did this last suicide attempt result in an injury or poisoning? 1_No 2_Yes 3_Don’t know

2.3.13 Did this last suicide attempt require medical attention? 1_No 2_Yes 3_Don’t know

2.3.14 Did this last suicide attempt require hospital admission for one night or longer? 1_No 2_Yes 3_Don’t know

2.4 Family history of suicidal behaviour: Have any of the following members of your biological family (i.e. related by birth only) died by suicide or made a suicide attempt?

2.4.1 Died by suicide:


2.4.2 Made a suicide attempt:


1 2 3 4 888 999

1 2 3 888 999

1 2 3 888 999

1 2 3 888 999

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

148



3.1 Height in cm _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.2 Weight in kg _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.3 Do you have any longstanding physical illness or disability that has troubled you for at least one year?

1 _ No 2 _ Yes

3.3.1 If yes, what is the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


In-patient psychiatric treatment (includes treatment on psychiatric ward of general hospital)

3.4 How many times, if ever, have you been treated in a psychiatric hospital, in a psychiatric ward of a general hospital, or in any other in-patient institution for people with mental problems? (Be sure that you refer to in-patient treatment, meaning: “you were in the hospital both night and day”).

1 _ Never 2 _ 1 time 3 _ 2-3 times 4 _ 4 times or more

If “Never” (1_), continue with: Out-patient psychiatric treatment and day care (3.6).

_ _ _ _ _ 888 999

_ _ _ _ _ 888 999

1 2 888 999

555 _ _ 888 999

1 2 3 4 888 999

149


3.5 If one or more times in-patient treatment:

Could you, as accurately as possible and for each admission separately describe: when you were admitted, how long you stayed there, and for which reasons you were admitted?

(Please start with the last admission).

Admission: Length of stay: Reason for admission: Month/Year Months

1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Out-patient psychiatric treatment and day care

3.6 Have you ever been in contact with one of the following professional services for treatment or advice? (TO BE FILLED IN ACCORDING TO NATIONAL SITUATION, codes should include treatment by private psychiatrist; an EXAMPLE (based on health services in the Netherlands) is given below for reference.)

(EXAMPLE)

3.6.1 Psychiatric service, polyclinic service 1 _ No 2 _ Yes 3.6.2 Psychiatric service, day-care 1 _ No 2 _ Yes 3.6.3 Community Mental Health Care 1 _ No 2 _ Yes 3.6.4 Private psychologist or psychiatrist 1 _ No 2 _ Yes 3.6.5 Consultation service for alcohol and

drug related problems 1 _ No 2 _ Yes 3.6.6 Consultation service for relational and

sexual problems 1 _ No 2 _ Yes

3.7 Other intervention for emotional problems: Have you ever received assistance for emotional problems from anyone else? For instance self-help groups like Alcoholics Anonymous, S.O.S. telephone services, etc.?

1 _ No 2 _ Yes; Specify: _ _ _ _ _ _ _ _ _

3.8 Do you or did you ever experience for prolonged periods of time (for over at least one year) troubles within yourself that hindered your functioning? (Examples: fears of places, anxiety to leave your house, excessive fear of people in general, depressive feelings, other emotions or thoughts that influenced you repeatedly like obsessions, e.g., to be compelled to clean yourself or your house, etc.).

1 _ No 2 _ Yes

3.8.1 If yes, what was the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

1 2 888 999

555 _ _ 888 999

150



4.1 In your life, which of the following substances (see DRUG CARD) have you ever used?

DRUG CARD

4.1.1 Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 1 _ No 2 _ Yes 4.1.2 Alcoholic beverages (beer, wine, liquor, etc.) 1 _ No 2 _ Yes 4.1.3 Marijuana (pot, grass, hash, etc.) 1 _ No 2 _ Yes 4.1.4 Cocaine or Crack 1 _ No 2 _ Yes 4.1.5 Stimulants or Amphetamines (speed, diet pills, ecstasy, etc.) 1 _ No 2 _ Yes 4.1.6 Inhalants (nitrous, glue, spray paint, gasoline, paint thinner) 1 _ No 2 _ Yes 4.1.7 Sedatives or Sleeping Pills (Valium, Librium, Xanax, Haldol,

Seconal, Quaaludes, etc.) 1 _ No 2 _ Yes 4.1.8 Hallucinogens (LSD, acid, mushrooms, PDP, Special K, etc.) 1 _ No 2 _ Yes 4.1.9 Heroin, Morphine, Methadone or Pain Medication (codeine,

Dilaudid, Darvon, Demoral, Percodan, Fiorional, etc.) 1 _ No 2 _ Yes 4.1.10 Other, specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 _ No 2 _ Yes

4.2 If yes to any of these items, in the past three months, how often have you used the substances you mentioned?

4.2.1 Tobacco products (cigarettes, chewing tobacco, cigars, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

4.2.2 Alcoholic beverages (beer, wine, liquor, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

4.2.3 Marijuana (pot, grass, hash, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

4.2.4 Cocaine or Crack? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

4.2.5 Stimulants or Amphetamines (speed, diet pills, ecstasy, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

4.2.6 Inhalants (nitrous, glue, spray paint, gasoline, paint thinner)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

4.2.7 Sedatives or Sleeping Pills (Valium, Librium, Xanax, Haldol, Seconal, Quaaludes, etc.)?


4.2.8 Hallucinogens (LSD, acid, mushrooms, PDP, Special K, etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

4.2.9 Heroin, Morphine, Methadone or Pain Medication (codeine, Dilaudid, Darvon, Demoral, Percodan, Fiorional, etc.)?


4.2.10 Other, specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily

1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999 1 2 888 999

1 2 888 999 1 2 888 999

1 2 888 999 1 2 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

1 2 3 4 5 888 999

151


5. COMMUNITY STRESS AND PROBLEMS

5.1 What do you think are some of the major problems facing your community today? (Please use your own words) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5.2 How serious do you think the following problems are for your community? (From “1” = not serious to “5” = very serious)

5.2.1 Housing 1 2 3 4 5 5.2.2 Crime 1 2 3 4 5 5.2.3 Poverty 1 2 3 4 5 5.2.4 Education 1 2 3 4 5 5.2.5 Government 1 2 3 4 5 5.2.6 Family Life 1 2 3 4 5 5.2.7 Transportation 1 2 3 4 5 5.2.8 Health Care 1 2 3 4 5 5.2.9 Job Security 1 2 3 4 5 5.2.10 Racial Prejudice 1 2 3 4 5 5.2.11 Pollution 1 2 3 4 5 5.2.12 Drug Abuse 1 2 3 4 5 5.2.13 Alcohol Abuse 1 2 3 4 5 5.2.14 Child and Spouse Abuse 1 2 3 4 5 5.2.15 Quality of life 1 2 3 4 5 5.2.16 Physical Security and Safety 1 2 3 4 5

5.3 In your opinion, how close and supportive of one another are the people of this .………? (From “1” = not close/supportive to “5” = very close/supportive)

5.3.1 Neighbourhood? 1 2 3 4 5 5.3.2 City? 1 2 3 4 5 5.3.3 Region? 1 2 3 4 5 5.3.4 Nation? 1 2 3 4 5

5.4 In your opinion, how hopeful and optimistic about the future are the people of this ……….? (From “1” = not hopeful/optimistic to “5” = hopeful/optimistic)

5.4.1 Neighbourhood? 1 2 3 4 5 5.4.2 City? 1 2 3 4 5 5.4.3 Region? 1 2 3 4 5 5.4.4 Nation? 1 2 3 4 5

1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999

1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999

1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999 1 2 3 4 5 888 999

152


Annex 4 COMMUNITY DESCRIPTION

SUPRE-MISS

INSTRUCTIONS

Under the best of circumstances, the community description should be filled in by a cultural psychologist, anthropologist or sociologist because of their training in this kind of research.

The questionnaire comprises a broad listing of socio-cultural and community indices and dimensions. In answering these items, efforts should be made to use both objective record data and data bases in combination with key informants or focus group members. The researchers should do their best to obtain accurate and valid data for their sites and should cite the unique cultural circumstances under which they have collected their data.

1. Please enter your professional background: _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _

2. Please describe your experience in your field shortly: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3. Please note any observations you have:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Appendix 3 – Qualitative community description questionnaire

153


COMMUNITY DESCRIPTION SUPRE-MISS

1. SOCIO-CULTURAL INDICES

A. External Socio-Cultural Context

1.1 Location Description and History _ _ _ _ _ _ _ _ _ _

1.2 Describe community location with regard to:

1.2.1 Physical environment _ _ _ _ _ _ _ _ _ _

1.2.2 Define and describe climate _ _ _ _ _ _ _ _ _ _

1.2.3 Urban-rural status, dynamics, and changes _ _ _ _ _ _ _ _ _ _

1.3 Describe location via a brief historical chronology (past 10 years) – Include at least 20 entries citing major political, economic, and social events: _ _ _ _ _ _ _ _ _ _

1.4 Describe socioenvironmental quality via: 1.4.1 Pollution problems and changes in pollution for patient’s setting:

1.4.1.1 Air _ _ _ _ _ _ _ _ _ _

1.4.1.2 Water _ _ _ _ _ _ _ _ _ _

1.4.1.3 Noise _ _ _ _ _ _ _ _ _ _

1.4.1.4 Visual _ _ _ _ _ _ _ _ _ _

1.4.2 Traffic congestion in patient's setting _ _ _ _ _ _ _ _ _ _

1.4.3 Crowding/density in terms of people/location unit (i.e., dwelling, neighbourhood, region) _ _ _ _ _ _ _ _

1.4.4 Homeless numbers and rates as an index of social stress _ _ _ _ _ _ _ _ _ _

1.5 Population Distribution

Describe and define:

1.5.1 Population _ _ _ _ _ _ _ _ _ _

154


1.5.2 Population parameters (e.g., gender, age, ethnicity, religion affiliation) _ _ _ _ _ _ _ _ _ _

1.5.3 Population density (i.e., see point 1.4.3 above) _ _ _ _ _ _ _ _ _ _

1.5.4 Ratio of urban versus rural population for major cities and for the country as a whole. _ _ _ _ _ _ _ _ _ _

1.6 Social structure

1.6.1 Gender status and roles. Comment particularly on status of women, especially with regard to homelife, work, employment, and other issues of equality. Address the genderization of the society and community. _ _ _ _ _ _ _ _ _ _

1.6.2 Patriarchy and matriarchy status, especially pattern of authority _ _ _ _ _ _ _ _ _ _

1.6.3 Age status and roles _ _ _ _ _ _ _ _ _ _

1.6.4 Migration patterns (In and Out) _ _ _ _ _ _ _ _ _ _

1.6.5 Family organization patterns (i.e., nuclear, extended, other) _ _ _ _ _ _ _ _ _ _

1.6.6 Marriage and divorce rates, mean age of marriage _ _ _ _ _ _ _ _ _ _

1.6.7 Educational distribution levels, opportunities, and access _ _ _ _ _ _ _ _ _ _

1.6.8 Percent school dropouts before age 16 and reasons (e.g., poverty, illness, poor school performance, disliked school, etc. _ _ _ _ _ _ _ _ _ _

1.6.9 Number of schools, private and public per 100,000 population. Include education institutions at all levels from elementary to college. _ _ _ _ _ _ _ _ _ _

1.6.10 Household qualities 1.6.10.1 Size or Mean number of people per household _ _ _ _ _ _ _ _ _ _

1.6.10.2 Number of single parent households _ _ _ _ _ _ _ _ _ _

1.6.10.3 Number of widow households _ _ _ _ _ _ _ _ _ _

1.6.10.4 Data on recent migration versus long-term residents from rural, other urban, and/or foreign. _ _ _ _ _ _ _ _ _ _

1.6.11 Occupational distribution and patterns _ _ _ _ _ _ _ _ _ _

155


B. Socio-Cultural and Linguistic

Describe:

1.7 Languages spoken _ _ _ _ _ _ _ _ _ _

1.8 Ethnic minority population composition/distribution _ _ _ _ _ _ _ _ _ _

1.9 Ethnic minority status and empowerment _ _ _ _ _ _ _ _ _ _

1.10 Estimated percent literacy _ _ _ _ _ _ _ _ _ _

1.11 Ethnic tensions and problems _ _ _ _ _ _ _ _ _ _

C. Social and Economic Structure

Describe:

1.12 GNP for country _ _ _ _ _ _ _ _ _ _

1.13 Dominant economic and employment patterns _ _ _ _ _ _ _ _ _ _

1.14 Unemployment rates and patterns _ _ _ _ _ _ _ _ _ _

1.15 Poverty level distributions _ _ _ _ _ _ _ _ _ _

1.16 Housing patterns/styles _ _ _ _ _ _ _ _ _ _

1.17 Industry and work patterns _ _ _ _ _ _ _ _ _ _

1.18 Percentage of families where both parents work _ _ _ _ _ _ _ _ _ _

1.19 Percent expenditures (if available) on food, housing, clothing, health, transportation, recreation (to see how money is spent) _ _ _ _ _ _ _ _ _ _

1.20 Number of tourists per year _ _ _ _ _ _ _ _ _ _

1.21 Number of banks _ _ _ _ _ _ _ _ _ _

1.22 Number of registered automobiles _ _ _ _ _ _ _ _ _ _

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D. Religious Systems

Describe:

1.23 Formal religions present in community via churches, temples, etc. _ _ _ _ _ _ _ _ _ _

1.24 Religious conflicts among groups _ _ _ _ _ _ _ _ _ _

1.25 Religious affiliation patterns and rates _ _ _ _ _ _ _ _ _ _

1.26 Number of churches, temples, or places of religious worship _ _ _ _ _ _ _ _ _ _

1.27 Religious rituals and ceremonies regarding death _ _ _ _ _ _ _ _ _ _

E. Communications/Media/Entertainment

Describe:

1.28 Number of newspapers _ _ _ _ _ _ _ _ _ _

1.29 Number of TV stations or cable _ _ _ _ _ _ _ _ _ _

1.30 Number of radio stations _ _ _ _ _ _ _ _ _ _

1.31 Describe most popular (circulation) items and why _ _ _ _ _ _ _ _ _ _

F. Health and Medical Dynamics

Describe:

1.32 Birth rates _ _ _ _ _ _ _ _ _ _

1.33 Life expectancy rates _ _ _ _ _ _ _ _ _ _

1.34 Number of western medicine physicians per 100,000 population _ _ _ _ _ _ _ _ _ _

1.35 Number of mental health professionals (i.e., psychiatrists, psychologists, social workers, nurses). See also Section H _ _ _ _ _ _ _ _ _ _

1.36 Number and types of indigenous healers. Describe availability, accessibility, and acceptability _ _ _ _ _ _ _ _ _

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1.37 Availability of special emergency telephone lines or services for suicide _ _ _ _ _ _ _ _ _ _

1.38 Number of hospitals _ _ _ _ _ _ _ _ _ _

1.39 Models of illness: Western, Supernatural, Social/Internal _ _ _ _ _ _ _ _ _ _

1.40 Number of deaths per year per 100,000 population _ _ _ _ _ _ _ _ _ _

1.41 Primary causes of death? _ _ _ _ _ _ _ _ _ _

1.42 Estimates of smoking rates _ _ _ _ _ _ _ _ _ _

1.43 Number of suicides per year in last ten years? _ _ _ _ _ _ _ _ _ _

1.44 Sanitation _ _ _ _ _ _ _ _ _ _

1.45 Recent epidemics or hysteria episodes _ _ _ _ _ _ _ _ _ _

G. Social Deviancy Patterns According to Demographic Markers

Describe:

1.46 Homicidal rates _ _ _ _ _ _ _ _ _ _

1.47 Crime rates _ _ _ _ _ _ _ _ _ _

1.48 Juvenile crime rates _ _ _ _ _ _ _ _ _ _

1.49 Alcohol rates _ _ _ _ _ _ _ _ _ _

1.50 Substance abuse rates _ _ _ _ _ _ _ _ _ _

1.51 Child and spouse abuse rates _ _ _ _ _ _ _ _ _ _

1.52 Prostitution rates _ _ _ _ _ _ _ _ _ _

1.53 Number of admissions to psychiatric facilities _ _ _ _ _ _ _ _ _ _

1.54 Sexual violence and abuse rates _ _ _ _ _ _ _ _ _ _

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H. Mental Health and Wellbeing

1.55 Resources for mental health including hospitals, clinics, mental health professionals, volunteer agencies, policies and plans. _ _ _ _ _ _ _ _ _ _

1.56 The distribution of mental health resources including issues of availability, accessibility, and acceptability. _ _ _ _ _ _ _ _ _ _

1.57 Status, salary, budgets, training of mental health personnel _ _ _ _ _ _ _ _ _ _

I. General Sociocultural Context

Describe:

1.58 Socio-cultural ethos, world views, and orientations as indexed by the following dimensions:

1.58.1 Materialism _ _ _ _ _ _ _ _ _ _ Spirituality _ _ _ _ _ _ _ _ _ _

1.58.2 Individualism _ _ _ _ _ _ _ _ _ _ Collectivism _ _ _ _ _ _ _ _ _ _

1.58.3 Competition _ _ _ _ _ _ _ _ _ _ Cooperation _ _ _ _ _ _ _ _ _ _

1.58.4 Change _ _ _ _ _ _ _ _ _ _ Tradition _ _ _ _ _ _ _ _ _ _

1.58.5 Product _ _ _ _ _ _ _ _ _ _ Process _ _ _ _ _ _ _ _ _ _

1.58.6 Scientism _ _ _ _ _ _ _ _ _ _ Intuition _ _ _ _ _ _ _ _ _ _

1.58.7 Westernization _ _ _ _ _ _ _ _ _ _ Traditional _ _ _ _ _ _ _ _ _ _

1.58.8 Time orientation (past, present, future) _ _ _ _ _ _ _ _ _ _

1.58.9 Perceptions of death and afterlife _ _ _ _ _ _ _ _ _ _

1.59 Socio-Cultural and Political Stability

Try to determine socio-cultural and political stability as indexed by the following dimensions:

1.59.1 Recent history of natural disaster in community _ _ _ _ _ _ _ _ _ _

1.59.2 Recent history of war or civil disturbances _ _ _ _ _ _ _ _ _ _

159


1.59.3 Governmental pattern and stability _ _ _ _ _ _ _ _ _ _

1.59.4 Levels of government and/or police/justice corruption _ _ _ _ _ _ _ _ _ _

1.59.5 Rapid social-technical change via industry, investment, land development _ _ _ _ _ _ _ _ _ _

1.59.6 Levels of crime and violence related to ethnopolitical strife _ _ _ _ _ _ _ _ _ _

1.59.7 Situation with regard to refugees and IDPs _ _ _ _ _ _ _ _ _ _

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2. SOCIO-CULTURAL CONTEXT OF SUICIDE QUESTIONS

It will be necessary to adjust the questions to the population under study.

2.1 What has been the historical cultural attitude toward suicide in your country (or cultural group or community)? That is to say, what have people thought about the act of committing suicide? (For example: ritualized suicide in Japan and India, or position of Catholic Church on suicide as sin)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.2 How has the cultural background of your country (cultural group or community) influenced the frequencies and kinds of ways people commit suicide? (For example: political system, educational system, attitudes toward women, attitudes toward drinking, religion, etc.)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.3 What has been the influence of your country’s (cultural group or community) history, geography/climate, and religion on the act of committing suicide? (For example: absence of sun in Northern European countries, exposure to toxic pollutants in Eastern Europe)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.4 Within the culture of your country, what is the attitude toward suicide today? (For example: euthanasia may be accepted, or may be seen as a final act of dignity and taking control of one’s life)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.5 What is the general attitude in your country (cultural group or community) toward a person who commits suicide? (For example: sympathy, condemnatory, critical, anger, etc.)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.6 What is the general attitude in your country (cultural group or community) toward the person who attempts suicide but survives? (For example: caring, guilt, anger, support)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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2.7 What is the general attitude in your country (cultural group or community) toward the family members of the suicide victim? (For example: caring, anger, distrust)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.8 What are the burial and mourning practices in your country (cultural group or community) for someone who has committed suicide? (For example: no religious service, burn body, avoid family members)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2.9 What references to suicide are found in your country’s (cultural group or community) religion, literature, songs, art? (For example: Masada deaths, The Bell Jar, John Donne’s “Self-Homicide”)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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3. CORONER’S QUESTIONS (ASCERTAINMENT OF SUICIDE)

3.1 Please describe the procedure for the ascertainment of suicide in your country.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.2 If ascertainment is made through a coroner, please describe the system used (i.e., To whom is the coroner responsible? What is the current legislation relating to the coroner’s office and functions?):

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.3 What are the instructions in the Coroner’s Act (or equivalent) that govern or are pertinent to the ascertainment of suicide?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.4 What qualifications do coroners have with regard to specific dimensions of their functioning?

1 _ Legal 2 _ Medical 3 _ Medico-Legal 4 _ Religious 5 _ Psychological

3.5 What options exist for the possible misclassification of suicidal deaths (e.g., open verdict, accidental death, undetermined death – please specify all options)?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.6 Taking each of the last ten years for which data are available, what were the numbers for each of the following in your country and community?

3.6.1 Suicides _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3.6.2 Accidental deaths _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3.6.3 Deaths with open verdict _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3.6.4 Undetermined deaths _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3.6.5 Homicides _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.7 What are the leading methods of suicide in your country/region, community?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3.8 Taking each of the last ten years for which data are available, what were the percentages for each of the five major methods of suicide?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

163

ELULOOKIRJELDUS

ISIKLIKUD ANDMED Nimi: Merike Sisask Sünniaeg: 28.07.1968 HARIDUS 2006-2010 Tallinna Ülikool, Rahvusvaheliste ja Sotsiaaluuringute Instituut

(sotsioloogia doktorant) 2005 Tartu Ülikool, Tervishoiu Instituut (MSc rahvatervishoius) 2000-2003 Professionaalse Psühholoogia Erakool (psühholoogiline nõustaja) 1986-1991 Tartu Ülikool, Õigusteaduskond (dipl iur) 1975-1986 Saku Gümnaasium AMETIKOHAD 2001-praegu Eesti-Rootsi Vaimse Tervise ja Suitsidoloogia Instituut (ERSI)

www.suicidology.ee (teadur; alates 2007 tegevdirektor) 2003-2007 Nõustamiskabinet “Sigmund” (psühholoogiline nõustaja) 2002-2007 Saku Päevakeskus (psühholoogiline nõustaja) 1995-2002 Saku Õlletehas (jurist) 1991-1995 Informatsiooni- ja Kaubanduskeskus ITC (jurist) UURIMISVALDKONNAD 1. Tervis, rahvatervishoid (suitsidaalne käitumine, suitsiidikatse sotsiaalsed, me-

ditsiinilised ja psüühilised riskitegurid, abiotsiv käitumine, kulu-efektiivsed preventsioonistrateegiad)

2. Sotsiaalteadused, kultuur ja ühiskond (vaimne tervis, suitsidaalne käitumine ja mõtlemine, suitsiidikatse sooritamist mõjutavad sotsiaal-demograafilised ja psühho-sotsiaalsed tegurid)

164

PUBLIKATSIOONID

Rahvusvahelised eelretsenseerimisega ajakirjad, tsiteeritud ISI Web of Science poolt

1. Yur'yev A, Värnik A, Värnik P, Sisask M, Leppik L. Role of social welfare in

suicide prevention in Europe. 2010 (avaldamiseks vastu võetud) 2. Yur'yev A, Värnik A, Värnik P, Sisask M, Leppik L. Employment status influ-

ences suicide mortality in Europe. International Journal of Social Psychiatry 2010; DOI: 10.1177/0020764010387059

3. Anderson A, Sisask M, Värnik A. Familicide and suicide in a case of gambling dependence. Journal of Forensic Psychiatry and Psychology 2010; DOI: 10.1080/14789949.2010.518244

4. Bertolote JM, Fleischmann A, De Leo D, Phillips M, Botega N, Vjayakumar L, De Silva D, Schlebusch L, Nguyen VT, Sisask M, Bolhari J, Wasserman D. Repetition of suicide attempts: data from five culturally different low- and middle-income country emergency care settings participating in the WHO SUPRE-MISS study. Crisis 2010;31(4):194-201

5. Yur'yev A, Leppik L, Tooding LM, Sisask M, Värnik P, Wu J, Värnik A. Social inclusion affects elderly suicide mortality. International Psychogeriatrics 2010; 22(8):1337-43

6. Heidmets L, Samm A, Sisask M, Kõlves K, Aasvee K, Värnik A. Sexual behavior, depressive feelings and suicidality among Estonian schoolchildren aged 13 to 15 years. Crisis 2010;31(3):128-36

7. Värnik P, Sisask M, Värnik A, Laido Z, Meise U, Ibelshäuser A, van Audenhove C, Reynders A, Kocalevent RD, Kopp M, Dosa A, Arensman E, Coffey C, van der Feltz-Cornelis CM, Gusmão R, Hegerl U. Suicide registration in eight European countries: a qualitative analysis of procedures and practices. Forensic Science International 2010;202:86-92

8. Wasserman D, Carli V, Wasserman C, Apter A, Balazs J, Bobes J, Brakale R, Brunner R, Bursztein-Lipsicas C, Corcoran P, Cosman D, Durkee T, Feldman D, Gadoros J, Guillemin F, Haring C, Kahn JP, Kaess M, Keeley H, Marusic D, Nemes B, Postuvan V, Reiter-Theil S, Resch F, Saiz P, Sarchiapone M, Sisask M, Varnik A, Hoven CW. Saving and Empowering Young Lives in Europe (SEYLE): a randomized controlled trial. BMC Public Health 2010;10(1):192

9. Scheerder G, van Audenhove C, Arensman E, Bernik B, Giupponi G, Horel AC, Maxwell M, Sisask M, Szekely A, Värnik A, Hegerl U. Community and health professionals' attitude toward depression: a pilot study in 9 EAAD countries. The International Journal of Social Psychiatry 2010; DOI:10.117/0020764009359742

10. Sisask M, Värnik A, Kõlves K, Bertolote JM, Bolhari J, Botega NJ, Fleischmann A, Vijayakumar L, Wasserman D. Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study. Archives of Suicide Research 2010;14(1):44-55

165

11. Samm A, Tooding LM, Sisask M, Kõlves K, Aasvee K, Värnik A. Suicidal thoughts and depressive feelings amongst Estonian schoolchildren: effect of family relationship and family structure. European Child & Adolescent Psychiatry 2010;19:457-68

12. Värnik P, Sisask M, Värnik A, Yur'yev A, Kõlves K, Leppik L, Nemtsov A, Wasserman D. Massive increase in injury deaths of undetermined intent in ex-USSR Baltic and Slavic countries: Hidden suicides? Scandinavian Journal of Public Health 2010;38(4):395-403

13. Sisask M, Värnik A, Kõlves K. Severity of attempted suicide as measured by the Pierce Suicidal Intent Scale. Crisis 2009;30(3):136-43

14. Sisask M, Värnik A, Kõlves K, Konstabel K, Wasserman D. Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. Nordic Journal of Psychiatry 2008;62(6):431-5

15. Tall K, Kõlves K, Sisask M, Värnik A. Do suicide survivors respond differently when alcohol abuse complicates suicide? Findings from the psychological autopsy study in Estonia. Drug and Alcohol Dependence 2008;95:129-33

16. Samm A, Värnik A, Tooding LM, Sisask M, Kõlves K, von Knorring AL. Children’s Depression Inventory in Estonia: Single items and factor structure by age and gender. European Child & Adolescent Psychiatry 2007;17(3):162-70

17. Kõlves K, Sisask M, Anion L, Samm A, Värnik A. Factors predicting suicide among Russians in Estonia in comparison with Estonians: case-control study. Croatian Medical Journal 2006; 47(6):869-77

18. Fleischmann A, Bertolote JM, Wasserman D, De Leo D, Botega N, Phillips M, Sisask M, Vjayakumar L, Malakouti K, Schlebusch L, De Silva D, Nguyen VT, Wasserman D. Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries. Psychological Medicine 2005; 35:1467-74

Muud rahvusvahelised eelretsenseerimisega ajakirjad 1. Hegerl U, Cibis A, Arensman E, Aromaa E, van Audenhove C, Bouleau JH,

van der Feltz-Cornelis CM, Giupponi G, Gusmäo R, Kopp M, Marusic A, Maxwell M, Meise U, Oskarsson H, Pull C, Ricka R, Schmidtke A, Pérez Sola V, Sisask M, Wittenburg L. European Alliance Against Depression - et fireplans intervensjonsprogram mot depresjon og suicidalitet [The „European Alliance Against Depression“ – a four-level intervention programme against depression and suicidality]. Suicidologi 2008;13(1):12-14

2. Värnik A, Kõlves K, Sisask M, Samm A, Wasserman D. Suicide mortality and political transition: Russians in Estonia compared to the Estonians in Estonia and the population of Russia. Trames 2006; 10(2):268-77

3. Sisask M, Värnik A, Wasserman D. Internet Comments on Media Reporting of Two Adolescents’ Collective Suicide Attempt. Archives of Suicide Research 2005;1:87-98

166

Eesti teadusajakirjad 1. Heidmets L, Samm A, Sisask M, Kõlves K, Visnapuu P, Aasvee K, Värnik A.

Depressiivsete ja suitsidaalsete kooliõpilaste seksuaalkäitumine. [Sexual behaviour of depressive and suicidal Estonian schoolchildren.] Eesti Arst 2009;88(3):156-63

2. Värnik A, Sisask M, Kõlves K. 15 aastat teadusuuringuid Eesti-Rootsi Vaimse Tervise ja Suitsidoloogia Instituudis: ülevaade tulemustest. [15 years of research at the Estonian-Swedish Mental Health and Suicidology Institute: overview of results.] Eesti Arst 2008;87(2):535-9

3. Sisask M, Kõlves K, Värnik A. Suitsidaalsus ühiskonnas ja suitsiidikatse soori-tamist prognoosivad tegurid. [Suicidality in society and the factors predicting suicide attempt.] Eesti Arst 2004;83:744-9

Muud teaduspublikatsioonid 1. Värnik A, Sisask M, Värnik P, editors. Baltic Suicide Paradox. Tallinn: Tallinn

University Press; 2010 2. Värnik A, Sisask M, Kõlves K, editors. Essential papers on suicidology 1993-

2008. To celebrate the 15th anniversary of ERSI. Tallinn: Estonian-Swedish Mental Health and Suicidology Institute (ERSI); 2008

JUHENDATUD MAGISTRITÖÖD 1. Siiri Tõniste. Tajutud sotsiaalne toetus suitsiidikatse sooritanute hulgas. Juhen-

dajad: Aleksander Pulver, Merike Sisask. Tallinn: Tallinna Ülikool, Sotsiaal-teaduskond; 2007

2. Eda Muru. Perearstipraksise sidusus vaimse tervise häiretega patsientide puhul. Juhendajad: Airi Värnik, Merike Sisask. Tallinn: Tallinna Ülikool, Sotsiaaltöö Instituut; 2008

3. Kertu Valling. Suitsiidijuhtumite kajastamine: analüüs Maailma Terviseorgani-satsiooni soovituslikest meediajuhistest lähtudes. Juhendaja: Merike Sisask. Tallinn: Tallinna Ülikool, Sotsiaaltöö Instituut; 2010

RAHVUSVAHELISED KONVERENTSID 1. Värnik P, Sisask M, Värnik A, Laido Z, Meise U, Ibelshäuser A, van

Audenhove C, Reynders A, Kocalevent RD, Kopp M, Dosa A, Arensman E, Coffey C, van der Feltz-Cornelis CM, Gusmão R, Hegerl U. Suicide registration procedures and practices in Europe. 10th World Conference on Injury Prevention and Safety Promotion, London, UK, 2010

2. Värnik P, Sisask M, Värnik A. Mental health and self-destructive behaviours among adolescents: Preliminary results of SEYLE in Estonia. 13th ESSSB, Rome, Italy, 2010

3. Laido Z, Yur’yev A, Sisask M, Värnik A. Definitions of suicide and non-fatal suicidal acts. 13th ESSSB, Rome, Italy, 2010

4. Yur’yev A, Värnik A, Värnik P, Sisask M, Leppik L. Employment status and suicide mortality in Europe. 13th ESSSB, Rome, Italy, 2010

167

5. Värnik P, Sisask M, Värnik A, Laido Z, Meise U, Ibelshäuser A, van Audenhove C, Reynders A, Kocalevent RD, Kopp M, Dosa A, Arensman E, Coffey C, van der Feltz-Cornelis CM, Gusmão R, Hegerl U. Suicide registration procedures and practices in Europe. 13th ESSSB, Rome, Italy, 2010

6. Sisask M, Anderson A, Heidmets L, Värnik A. Familicide-suicide in a case of gambling dependance: implications for military environment. International Military Testing Association (IMTA) Conference, Tartu, Estonia, 2009

7. Sisask M, Värnik A, Kõlves K, Konstabel K, Wasserman D. Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. 29th Nordic Congress of Psychiatry (Session: Best research from all countries published in Nordic Journal of Psychiatry in 2006-2008), Stockholm, Sweden, 2009

8. Hegerl U, Värnik A, Sisask M, Kõlves K, and the EAAD group. European Alliance Against Depression (EAAD). 5th World Conference on the Promotion of Mental Health and the Prevention of Mental and Behavioral Disorders, Mel-bourne, Australia, 2008

9. Sisask M, Värnik A. Family homicide-suicide of a military man: a case analysis. 12th ESSSB, Glasgow, Scotland, 2008, S10.3.2

10. Kõlves K, Yur'yev A, Sisask M, Grauberg M, Värnik A. Trends of male suicides and undetermined deaths in Baltic and Slavic ex-USSR countries, 1980-2005. 12th ESSSB, Glasgow, Scotland, 2008, P.080

11. Samm A, Sisask M, Kõlves K, Aasvee K, Tooding LM, Värnik A. Suicidal thoughts and depressive feelings in the context of family relations among schoolchildren in Estonia. 12th ESSSB, Glasgow, Scotland, 2008, P.118

12. Sisask M, Värnik A. Brief intervention after attempted suicide: findings from WHO SUPRE-MISS in Estonia. 9th World Conference on Injury Prevention and Safety Promotion, Merida, Mexico, 2008

13. Samm A, Kõlves K, Sisask M, Aasvee K, Tooding LM, Värnik A. Suicide ideation and mental health in relation to family functioning among schoolchildren in Estonia. VIIIth International Conference on Asian Youth and Childhoods, Lucknow, India, 2007

14. Sisask M, Värnik A. Family Homicide-Suicide of a Military Man: a case analysis. NATO Advanced Research Workshop “Wounds of War: Lowering Suicide Risk in Returning Troops”, Klopeiner See, Austria, 2007

15. Kalda R, Sisask M, Kempkens D, Värnik A, Ööpik P, Maaroos HI. Family doctors’ perceived obstacles in caring people with depressive symptoms in Es-tonia: preliminary results from an international study. 13th Wonca Europe Conference, Paris, France, 2007, 887

16. Sisask M, Värnik A, Kõlves K, Wasserman D, De Leo D, Berolote JM, Botega N, Phillips M, Vijayakumar L, Bolhari J, Schlebusch L, De Silva D, Nguyen VT, Fleischmann A. Subjective psychological well-being WHO-5 in assessment of the severity of suicide attempt: WHO SUPRE-MISS study. XXIV World Congress of IASP, Killarney, Ireland, 2007, OR069

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17. Raudsepp J, Sisask M, Värnik A, De Leo D, Wasserman D, Fleischmann A, Botega N, Phillips M, Vijayakumar L, Bolhari J, Schlebusch L, De Silva D, Nguyen VT, Berolote JM. Does religion pretect against suicide attempt: WHO SUPRE-MISS study. XXIV World Congress of IASP, Killarney, Ireland, 2007, OR022

18. Sisask M, Värnik A, Maaroos HI, Rieger MA, Kempkens D. Opportunities and obstacles of depression treatment in primary care. 11th ESSSB, Portorož, Slovenia. Psychiatria Danubina 2006, 18(Suppl 1), 117

19. Teepalu K, Pruul P, Sisask M, Värnik A. Gender differences in public attitude about depression. 11th ESSSB, Portorož, Slovenia. Psychiatria Danubina 2006, 18(Suppl 1), 116

20. Samm A, Värnik A, Kõlves K, Sisask M, von Knorring AL. The prevalence of depressive symptoms in schoolchildren in Estonia. 11th ESSSB, Portorož, Slovenia. Psychiatria Danubina 2006, 18(Suppl 1), 41

21. Kõlves K, Sisask M, Värnik A. Factors predicting suicide among Estonian Russians and Estonians. 11th ESSSB, Portorož, Slovenia. Psychiatria Danubina 2006, 18(Suppl 1), 62

22. Sisask M, Värnik A, Wasserman D. Internet comments on media reporting of a suicide attempt. 10th ESSSB, Copenhagen, Denmark, 2004, PO7.1

23. Sisask M, Kõlves K, Värnik A, Wasserman D. SUPRE-MISS in Estonia – main risk groups among suicide attempters. XXII World Congress of IASP, Stockholm, Sweden, 2003, 102:3

24. Tihaste M, Sisask M, Värnik A, Wasserman D. WHO SUPRE-MISS: Rehabilitation for suicide attempters. XXII World Congress of IASP, Stock-holm, Sweden, 2003, 110:1

25. Sisask M, Värnik A, Wasserman D. Suicidal behaviour among young people in Estonia: A case analysis. 9th ESSSB, Warwick, England, 2002, PO22

26. Sisask M, Värnik A, Wasserman D. Suicide prevention in a post-soviet society: case of Estonia. 1st Asian Regional Conference on Safe Communities, Suwon, South-Korea, 2002, T3B

KONVERENTSID EESTIS 1. Sisask M & SEYLE grupp. Väsimuse mõju teismeliste vaimsele tervisele.

Eesti Käitumis- ja Terviseteaduste Keskuse IX Aastakonverents, Lepanina, 2010

2. Värnik P, Sisask M, Laido Z, Värnik A. Suitsiidide registreerimine ning selle mõju ebaselge tahtlusega surmade arvukusele. Eesti Käitumis- ja Tervisetea-duste Keskuse VIII Aastakonverents, Vihula, 2010

3. Sisask M, Värnik A, Kõlves K, Bertolote JM, Bolhari J, Botega NJ, Fleischmann A, Vijayakumar L, Wasserman D. Religioossus kui kaitsetegur suitsiidikatse vastu: WHO SUPRE-MISS juhtkontroll uuring. Eesti Käitumis- ja Terviseteaduste Keskuse VII Aastakonverents, Narva-Jõesuu, 2008

4. Sisask M, Värnik A, Kõlves K, Wasserman D, De Leo D, Berolote JM, Botega N, Phillips M, Vijayakumar L, Bolhari J, Schlebusch L, De Silva D, Nguyen

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VT, Fleischmann A. Subjektiivne psühholoogiline heaolu suitsiidikatse raskus-astme määratlemisel. Eesti Käitumis- ja Terviseteaduste Keskuse VI Aastakon-verents, Toila, 2007

5. Sisask M, Kõlves K, Samm A, Anion L, Raudsepp J, Värnik A. Suitsiidikatse raskusastme määratlus ja selle seos psüühilise seisundiga. Eesti Käitumis- ja Terviseteaduste Keskuse V Aastakonverents, Roosta, 2006

6. Sisask M, Värnik A. WHO SUPRE-MISS: Suitsiidikatse sooritanute psüühili-ne terviseseisund ja kontakt tervishoiuasutustega. Eesti Käitumis- ja Tervise-teaduste Keskuse IV Aastakonverents, Pärnu, 2005

7. Sisask M, Värnik A. Depressioon ja suitsidaalsus: avalikkuse hoiak ja teadlik-kus. Eesti Sotsiaalteaduste VI Aastakonverents, Tallinn, 2005

8. Sisask M, Värnik A. Suitsiidikatse kajastamine meedias ja sellelejärgnenud Interneti kommentaarid. Eesti Käitumis- ja Terviseteaduste Keskuse III Aasta-konverents, Võru-Kubija, 2004

9. Sisask M, Värnik A. Kahe teismelise ühise suitsiidikatse kajastamine meedias ja sellele järgnenud Interneti kommentaarid. Eesti Sotsiaalteaduste V Aasta-konverents, Tartu, 2004

10. Sisask M, Kõlves K, Värnik A. WHO-SUPRE: Ülemaailmne suitsiidikatsete uuring Eestis. Eesti Käitumis- ja Terviseteaduste Keskuse II Aastakonverents, Pühajärve, 2003

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CURRICULUM VITAE

PERSONAL DATA Name: Merike Sisask Date of birth: 28.07.1968 EDUCATION 2006-2010 Tallinn University, Institute of International and social studies

(PhD student in sociology) 2005 University of Tartu, Department of Public Health (MSc in public

health) 2000-2003 The Private School of Professional Psychology (psychological

counsellor) 1986-1991 University of Tartu, Law Faculty (dipl iur) 1975-1986 Saku Gymnasium PROFESSIONAL POSITIONS 2001-present Estonian-Swedish Mental Health and Suicidology Institute (ERSI)

www.suicidology.ee (researcher; executive director since 2007) 2003-2007 Private practice “Sigmund” (psychological counsellor) 2002-2007 Saku Day-care Centre (psychological counsellor) 1995-2002 Saku Brewery (legal counsellor) 1991-1995 Information and Trading Centre ITC (legal counsellor) FIELDS OF RESEARCH 1. Health, Public Health Science (suicidal behaviour, social, medical and psychic

factors of attempted suicide, help-seeking behaviour, cost-effective prevention strategies)

2. Social Sciences, Culture and Society (mental health, suicidal behaviour and ideation, socio-demographic and psycho-social factors of attempted suicide)

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PUBLICATIONS

International peer-reviewed journals cited in ISI Web of Science 1. Yur'yev A, Värnik A, Värnik P, Sisask M, Leppik L. Role of social welfare in

suicide prevention in Europe. 2010 (accepted) 2. Yur'yev A, Värnik A, Värnik P, Sisask M, Leppik L. Employment status influ-

ences suicide mortality in Europe. International Journal of Social Psychiatry 2010; DOI: 10.1177/0020764010387059

3. Anderson A, Sisask M, Värnik A. Familicide and suicide in a case of gambling dependence. Journal of Forensic Psychiatry and Psychology 2010; DOI: 10.1080/14789949.2010.518244

4. Bertolote JM, Fleischmann A, De Leo D, Phillips M, Botega N, Vjayakumar L, De Silva D, Schlebusch L, Nguyen VT, Sisask M, Bolhari J, Wasserman D. Repetition of suicide attempts: data from five culturally different low- and middle-income country emergency care settings participating in the WHO SUPRE-MISS study. Crisis 2010;31(4):194-201

5. Yur'yev A, Leppik L, Tooding LM, Sisask M, Värnik P, Wu J, Värnik A. So-cial inclusion affects elderly suicide mortality. International Psychogeriatrics 2010; 22(8):1337-43

6. Heidmets L, Samm A, Sisask M, Kõlves K, Aasvee K, Värnik A. Sexual beha-vior, depressive feelings and suicidality among Estonian schoolchildren aged 13 to 15 years. Crisis 2010;31(3):128-36

7. Värnik P, Sisask M, Värnik A, Laido Z, Meise U, Ibelshäuser A, van Auden-hove C, Reynders A, Kocalevent RD, Kopp M, Dosa A, Arensman E, Coffey C, van der Feltz-Cornelis CM, Gusmão R, Hegerl U. Suicide registration in eight European countries: a qualitative analysis of procedures and practices. Fo-rensic Science International 2010;202:86-92

8. Wasserman D, Carli V, Wasserman C, Apter A, Balazs J, Bobes J, Brakale R, Brunner R, Bursztein-Lipsicas C, Corcoran P, Cosman D, Durkee T, Feldman D, Gadoros J, Guillemin F, Haring C, Kahn JP, Kaess M, Keeley H, Marusic D, Nemes B, Postuvan V, Reiter-Theil S, Resch F, Saiz P, Sarchiapone M, Sisask M, Varnik A, Hoven CW. Saving and Empowering Young Lives in Europe (SEYLE): a randomized controlled trial. BMC Public Health 2010;10(1):192

9. Scheerder G, van Audenhove C, Arensman E, Bernik B, Giupponi G, Horel AC, Maxwell M, Sisask M, Szekely A, Värnik A, Hegerl U. Community and health professionals' attitude toward depression: a pilot study in 9 EAAD coun-tries. The International Journal of Social Psychiatry 2010; DOI:10.117/0020764009359742

10. Sisask M, Värnik A, Kõlves K, Bertolote JM, Bolhari J, Botega NJ, Fleisch-mann A, Vijayakumar L, Wasserman D. Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study. Archives of Sui-cide Research 2010;14(1):44-55

11. Samm A, Tooding LM, Sisask M, Kõlves K, Aasvee K, Värnik A. Suicidal thoughts and depressive feelings amongst Estonian schoolchildren: effect of

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family relationship and family structure. European Child & Adolescent Psy-chiatry 2010;19:457-68

12. Värnik P, Sisask M, Värnik A, Yur'yev A, Kõlves K, Leppik L, Nemtsov A, Wasserman D. Massive increase in injury deaths of undetermined intent in ex-USSR Baltic and Slavic countries: Hidden suicides? Scandinavian Journal of Public Health 2010;38(4):395-403

13. Sisask M, Värnik A, Kõlves K. Severity of attempted suicide as measured by the Pierce Suicidal Intent Scale. Crisis 2009;30(3):136-43

14. Sisask M, Värnik A, Kõlves K, Konstabel K, Wasserman D. Subjective psy-chological well-being (WHO-5) in assessment of the severity of suicide at-tempt. Nordic Journal of Psychiatry 2008;62(6):431-5

15. Tall K, Kõlves K, Sisask M, Värnik A. Do suicide survivors respond differ-ently when alcohol abuse complicates suicide? Findings from the psychological autopsy study in Estonia. Drug and Alcohol Dependence 2008;95:129-33

16. Samm A, Värnik A, Tooding LM, Sisask M, Kõlves K, von Knorring AL. Children’s Depression Inventory in Estonia: Single items and factor structure by age and gender. European Child & Adolescent Psychiatry 2007;17(3):162-70

17. Kõlves K, Sisask M, Anion L, Samm A, Värnik A. Factors predicting suicide among Russians in Estonia in comparison with Estonians: case-control study. Croatian Medical Journal 2006; 47(6):869-77

18. Fleischmann A, Bertolote JM, Wasserman D, De Leo D, Botega N, Phillips M, Sisask M, Vjayakumar L, Malakouti K, Schlebusch L, De Silva D, Nguyen VT, Wasserman D. Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries. Psychological Medicine 2005; 35:1467-74

Other international peer-reviewed journals 1. Hegerl U, Cibis A, Arensman E, Aromaa E, van Audenhove C, Bouleau JH,

van der Feltz-Cornelis CM, Giupponi G, Gusmäo R, Kopp M, Marusic A, Maxwell M, Meise U, Oskarsson H, Pull C, Ricka R, Schmidtke A, Pérez Sola V, Sisask M, Wittenburg L. European Alliance Against Depression - et fireplans intervensjonsprogram mot depresjon og suicidalitet [The „European Alliance Against Depression“ – a four-level intervention programme against depression and suicidality]. Suicidologi 2008;13(1):12-14

2. Värnik A, Kõlves K, Sisask M, Samm A, Wasserman D. Suicide mortality and political transition: Russians in Estonia compared to the Estonians in Estonia and the population of Russia. Trames 2006; 10(2):268-77

3. Sisask M, Värnik A, Wasserman D. Internet Comments on Media Reporting of Two Adolescents’ Collective Suicide Attempt. Archives of Suicide Research 2005;1:87-98

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Estonian scientific journals 1. Heidmets L, Samm A, Sisask M, Kõlves K, Visnapuu P, Aasvee K, Värnik A.

Depressiivsete ja suitsidaalsete kooliõpilaste seksuaalkäitumine. [Sexual behaviour of depressive and suicidal Estonian schoolchildren.] Eesti Arst 2009;88(3):156-63

2. Värnik A, Sisask M, Kõlves K. 15 aastat teadusuuringuid Eesti-Rootsi Vaimse Tervise ja Suitsidoloogia Instituudis: ülevaade tulemustest. [15 years of research at the Estonian-Swedish Mental Health and Suicidology Institute: overview of results.] Eesti Arst 2008;87(2):535-9

3. Sisask M, Kõlves K, Värnik A. Suitsidaalsus ühiskonnas ja suitsiidikatse soori-tamist prognoosivad tegurid. [Suicidality in society and the factors predicting suicide attempt.] Eesti Arst 2004;83:744-9

Other scientific publications 1. Värnik A, Sisask M, Värnik P, editors. Baltic Suicide Paradox. Tallinn: Tallinn

University Press; 2010 2. Värnik A, Sisask M, Kõlves K, editors. Essential papers on suicidology 1993-

2008. To celebrate the 15th anniversary of ERSI. Tallinn: Estonian-Swedish Mental Health and Suicidology Institute (ERSI); 2008

SUPERVISED DISSERTATIONS (MASTER’S THESIS) 1. Siiri Tõniste. Tajutud sotsiaalne toetus suitsiidikatse sooritanute hulgas. [Per-

ceived social support among suicide attempters.] Supervisors: Aleksander Pul-ver, Merike Sisask. Tallinn: Tallinn University, Social Department; 2007

2. Eda Muru. Perearstipraksise sidusus vaimse tervise häiretega patsientide puhul. [The coherency between general practice and social work in case of patients with mental disorders.] Supervisors: Airi Värnik, Merike Sisask. Tallinn: Tal-linn University, Institute of Social Work; 2008

3. Kertu Valling. Suitsiidijuhtumite kajastamine: analüüs Maailma Terviseorgani-satsiooni soovituslikest meediajuhistest lähtudes. [Reporting of suicide cases: analysis based on the World Health Organization media guidelines.] Supervi-sor: Merike Sisask. Tallinn: Tallinn University, Institute of Social Work; 2010

INTERNATIONAL CONFERENCES 1. Värnik P, Sisask M, Värnik A, Laido Z, Meise U, Ibelshäuser A, van Auden-

hove C, Reynders A, Kocalevent RD, Kopp M, Dosa A, Arensman E, Coffey C, van der Feltz-Cornelis CM, Gusmão R, Hegerl U. Suicide registration pro-cedures and practices in Europe. 10th World Conference on Injury Prevention and Safety Promotion, London, UK, 2010

2. Värnik P, Sisask M, Värnik A. Mental health and self-destructive behaviours among adolescents: Preliminary results of SEYLE in Estonia. 13th ESSSB, Rome, Italy, 2010

3. Laido Z, Yur’yev A, Sisask M, Värnik A. Definitions of suicide and non-fatal suicidal acts. 13th ESSSB, Rome, Italy, 2010

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4. Yur’yev A, Värnik A, Värnik P, Sisask M, Leppik L. Employment status and suicide mortality in Europe. 13th ESSSB, Rome, Italy, 2010

5. Värnik P, Sisask M, Värnik A, Laido Z, Meise U, Ibelshäuser A, van Auden-hove C, Reynders A, Kocalevent RD, Kopp M, Dosa A, Arensman E, Coffey C, van der Feltz-Cornelis CM, Gusmão R, Hegerl U. Suicide registration pro-cedures and practices in Europe. 13th ESSSB, Rome, Italy, 2010

6. Sisask M, Anderson A, Heidmets L, Värnik A. Familicide-suicide in a case of gambling dependance: implications for military environment. International Military Testing Association (IMTA) Conference, Tartu, Estonia, 2009

7. Sisask M, Värnik A, Kõlves K, Konstabel K, Wasserman D. Subjective psy-chological well-being (WHO-5) in assessment of the severity of suicide at-tempt. 29th Nordic Congress of Psychiatry (Session: Best research from all countries published in Nordic Journal of Psychiatry in 2006-2008), Stockholm, Sweden, 2009

8. Hegerl U, Värnik A, Sisask M, Kõlves K, and the EAAD group. European Alliance Against Depression (EAAD). 5th World Conference on the Promotion of Mental Health and the Prevention of Mental and Behavioral Disorders, Mel-bourne, Australia, 2008

9. Sisask M, Värnik A. Family homicide-suicide of a military man: a case analy-sis. 12th ESSSB, Glasgow, Scotland, 2008, S10.3.2

10. Kõlves K, Yur'yev A, Sisask M, Grauberg M, Värnik A. Trends of male sui-cides and undetermined deaths in Baltic and Slavic ex-USSR countries, 1980-2005. 12th ESSSB, Glasgow, Scotland, 2008, P.080

11. Samm A, Sisask M, Kõlves K, Aasvee K, Tooding LM, Värnik A. Suicidal thoughts and depressive feelings in the context of family relations among schoolchildren in Estonia. 12th ESSSB, Glasgow, Scotland, 2008, P.118

12. Sisask M, Värnik A. Brief intervention after attempted suicide: findings from WHO SUPRE-MISS in Estonia. 9th World Conference on Injury Prevention and Safety Promotion, Merida, Mexico, 2008

13. Samm A, Kõlves K, Sisask M, Aasvee K, Tooding LM, Värnik A. Suicide ideation and mental health in relation to family functioning among schoolchil-dren in Estonia. VIIIth International Conference on Asian Youth and Child-hoods, Lucknow, India, 2007

14. Sisask M, Värnik A. Family Homicide-Suicide of a Military Man: a case analysis. NATO Advanced Research Workshop “Wounds of War: Lowering Suicide Risk in Returning Troops”, Klopeiner See, Austria, 2007

15. Kalda R, Sisask M, Kempkens D, Värnik A, Ööpik P, Maaroos HI. Family doctors’ perceived obstacles in caring people with depressive symptoms in Es-tonia: preliminary results from an international study. 13th Wonca Europe Con-ference, Paris, France, 2007, 887

16. Sisask M, Värnik A, Kõlves K, Wasserman D, De Leo D, Berolote JM, Botega N, Phillips M, Vijayakumar L, Bolhari J, Schlebusch L, De Silva D, Nguyen VT, Fleischmann A. Subjective psychological well-being WHO-5 in assess-

175

ment of the severity of suicide attempt: WHO SUPRE-MISS study. XXIV World Congress of IASP, Killarney, Ireland, 2007, OR069

17. Raudsepp J, Sisask M, Värnik A, De Leo D, Wasserman D, Fleischmann A, Botega N, Phillips M, Vijayakumar L, Bolhari J, Schlebusch L, De Silva D, Nguyen VT, Berolote JM. Does religion pretect against suicide attempt: WHO SUPRE-MISS study. XXIV World Congress of IASP, Killarney, Ireland, 2007, OR022

18. Sisask M, Värnik A, Maaroos HI, Rieger MA, Kempkens D. Opportunities and obstacles of depression treatment in primary care. 11th ESSSB, Portorož, Slo-venia. Psychiatria Danubina 2006, 18(Suppl 1), 117

19. Teepalu K, Pruul P, Sisask M, Värnik A. Gender differences in public attitude about depression. 11th ESSSB, Portorož, Slovenia. Psychiatria Danubina 2006, 18(Suppl 1), 116

20. Samm A, Värnik A, Kõlves K, Sisask M, von Knorring AL. The prevalence of depressive symptoms in schoolchildren in Estonia. 11th ESSSB, Portorož, Slo-venia. Psychiatria Danubina 2006, 18(Suppl 1), 41

21. Kõlves K, Sisask M, Värnik A. Factors predicting suicide among Estonian Russians and Estonians. 11th ESSSB, Portorož, Slovenia. Psychiatria Danubina 2006, 18(Suppl 1), 62

22. Sisask M, Värnik A, Wasserman D. Internet comments on media reporting of a suicide attempt. 10th ESSSB, Copenhagen, Denmark, 2004, PO7.1

23. Sisask M, Kõlves K, Värnik A, Wasserman D. SUPRE-MISS in Estonia – main risk groups among suicide attempters. XXII World Congress of IASP, Stockholm, Sweden, 2003, 102:3

24. Tihaste M, Sisask M, Värnik A, Wasserman D. WHO SUPRE-MISS: Rehabili-tation for suicide attempters. XXII World Congress of IASP, Stockholm, Swe-den, 2003, 110:1

25. Sisask M, Värnik A, Wasserman D. Suicidal behaviour among young people in Estonia: A case analysis. 9th ESSSB, Warwick, England, 2002, PO22

26. Sisask M, Värnik A, Wasserman D. Suicide prevention in a post-soviet society: case of Estonia. 1st Asian Regional Conference on Safe Communities, Suwon, South-Korea, 2002, T3B

CONFERENCES IN ESTONIA 1. Sisask M & SEYLE group. Väsimuse mõju teismeliste vaimsele tervisele.

[Fatigue in relation to pupils’ mental health.] IX Annual Conference of Esto-nian Centre for Behavioural and Health Sciences, Lepanina, 2010

2. Värnik P, Sisask M, Laido Z, Värnik A. Suitsiidide registreerimine ning selle mõju ebaselge tahtlusega surmade arvukusele. [Suicide registration and its im-pact on the prevalence of the deaths with undetermined intent.] VIII Annual Conference of Estonian Centre for Behavioural and Health Sciences, Vihula, 2010

3. Sisask M, Värnik A, Kõlves K, Bertolote JM, Bolhari J, Botega NJ, Fleisch-mann A, Vijayakumar L, Wasserman D. Religioossus kui kaitsetegur suitsiidi-

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katse vastu: WHO SUPRE-MISS juhtkontroll uuring. [Religiosity as a protec-tive factor against attempted suicide: WHO SUPRE-MISS case-control study.] VII Annual Conference of Estonian Centre for Behavioural and Health Sci-ences, Narva-Jõesuu, 2008

4. Sisask M, Värnik A, Kõlves K, Wasserman D, De Leo D, Berolote JM, Botega N, Phillips M, Vijayakumar L, Bolhari J, Schlebusch L, De Silva D, Nguyen VT, Fleischmann A. Subjektiivne psühholoogiline heaolu suitsiidikatse rasku-sastme määratlemisel. [Subjective psychological well-being in assessment of the severity of suicide attempt.] VI Annual Conference of Estonian Centre for Behavioural and Health Sciences, Toila, 2007

5. Sisask M, Kõlves K, Samm A, Anion L, Raudsepp J, Värnik A. Suitsiidikatse raskusastme määratlus ja selle seos psüühilise seisundiga. [Assessment of the severity of suicide attempt and association with psychic status.] V Annual Con-ference of Estonian Centre for Behavioural and Health Sciences, Roosta, 2006

6. Sisask M, Värnik A. WHO SUPRE-MISS: Suitsiidikatse sooritanute psüühiline terviseseisund ja kontakt tervishoiuasutustega. [Psychic health status and contact with health care services among suicide attempters.] IV Annual Conference of Estonian Centre for Behavioural and Health Sciences, Pärnu, 2005

7. Sisask M, Värnik A. Depressioon ja suitsidaalsus: avalikkuse hoiak ja teadlik-kus. [Depression and suicidality: public attitude and awareness.] VI Annual Conference of Estonian Social Sciences, Tallinn, 2005

8. Sisask M, Värnik A. Suitsiidikatse kajastamine meedias ja sellelejärgnenud Interneti kommentaarid. [Media portrayal of a suicide attempt and following comments in the Internet.] III Annual Conference of Estonian Centre for Be-havioural and Health Sciences, Võru-Kubija, 2004

9. Sisask M, Värnik A. Kahe teismelise ühise suitsiidikatse kajastamine meedias ja sellele järgnenud Interneti kommentaarid. [Media portrayal of a teenagers’ simultaneous suicide attempt and following comments in the Internet.] V An-nual Conference of Estonian Social Sciences, Tartu, 2004

10. Sisask M, Kõlves K, Värnik A. WHO-SUPRE: Ülemaailmne suitsiidikatsete uuring Eestis. [WHO SUPRE-MISS: Worldwide study of suicide attempts in Estonia.] II Annual Conference of Estonian Centre for Behavioural and Health Sciences, Pühajärve, 2003

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TALLINNA ÜLIKOOL SOTSIAALTEADUSTE DISSERTATSIOONID TALLINN UNIVERSITY DISSERTATIONS ON SOCIAL SCIENCES 1. MARE LEINO. Sotsiaalsed probleemid koolis ja õpetaja toimetulek. Tallinna Peda-

googikaülikool. Sotsiaalteaduste dissertatsioonid, 1. Tallinn: TPÜ kirjastus, 2002. 125 lk. ISSN 1406-4405. ISBN 9985-58-227-6.

2. MAARIS RAUDSEPP. Loodussäästlikkus kui regulatiivne idee: sotsiaal-psühholoogi-line analüüs. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 2. Tallinn: TPÜ kirjastus, 2002. 162 lk. ISSN 1406-4405. ISBN 9985-58-231-4.

3. EDA HEINLA. Lapse loova mõtlemise seosed sotsiaalsete ja käitumisteguritega. Tallin-na Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 3. Tallinn: TPÜ kirjastus, 2002. 150 lk. ISSN 1406-4405. ISBN 9985-58-240-3.

4. KURMO KONSA. Eestikeelsete trükiste seisundi uuring. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 4. Tallinn: TPÜ kirjastus, 2003. 122 lk. ISSN 1406-4405. ISBN 9985-58-245-2.

5. VELLO PAATSI. Eesti talurahva loodusteadusliku maailmapildi kujunemine rahvakooli kaudu (1803–1918). Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 5. Tal-linn: TPÜ kirjastus, 2003. 206 lk. ISSN 1406-4405. ISBN 9985-58-247-0.

6. KATRIN PAADAM. Constructing Residence as Home: Homeowners and Their Housing Histories. Tallinn Pedagogical University. Dissertations on Social Sciences, 6. Tallinn: TPU Press, 2003. 322 p. ISSN 1406-4405. ISBN 9985-58-268-3.

7. HELI TOOMAN. Teenindusühiskond, teeninduskultuur ja klienditeenindusõppe konsep-tuaalsed lähtekohad. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 7. Tal-linn: TPÜ kirjastus, 2003. 368 lk. ISSN 1406-4405. ISBN 9985-58-287-X.

8. KATRIN NIGLAS. The Combined Use of Qualitative and Quantitative Metods in Edu-cational Research. Tallinn Pedagogical University. Dissertations on Social Sciences, 8. Tal-linn: TPU Press, 2004. 200 p. ISSN 1406-4405. ISBN 9985-58-298-5.

9. INNA JÄRVA. Põlvkondlikud muutused Eestimaa vene perekondade kasvatuses: sotsio-kultuuriline käsitus. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 9. Tal-linn: TPÜ kirjastus, 2004. 202 lk. ISSN 1406-4405. ISBN 9985-58-311-6.

10. MONIKA PULLERITS. Muusikaline draama algõpetuses – kontseptsioon ja rakendus-võimalusi lähtuvalt C. Orffi süsteemist. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dis-sertatsioonid, 10. Tallinn: TPÜ kirjastus, 2004. 156 lk. ISSN 1406-4405. ISBN 9985-58-309-4.

11. MARJU MEDAR. Ida-Virumaa ja Pärnumaa elanike toimetulek: sotsiaalteenuste vaja-dus, kasutamine ja korraldus. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioo-nid, 11. Tallinn: TPÜ kirjastus, 2004. 218 lk. ISSN 1406-4405. ISBN 9985-58-320-5.

12. KRISTA LOOGMA. Töökeskkonnas õppimise tähendus töötajate kohanemisel töötingi-mustega. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 12. Tallinn: TPÜ kirjastus, 2004. 238 lk. ISSN 1406-4405. ISBN 9985-58-326-4.

13. МАЙЯ МУЛДМА. Феномен музыки в формировании диалога культур (сопостави-тельный анализ мнений учителей музыки школ с эстонским и русским языком

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обучения). Таллиннский педагогический университет. Диссертации по социальным наукам, 13. Таллинн: Изд-во ТПУ, 2004. 209 c. ISSN 1406-4405. ISBN 9985-58-330-2.

14. EHA RÜÜTEL. Sociocultural Context of Body Dissatisfaction and Possibilities of Vibro-acoustic Therapy in Diminishing Body Dissatisfaction. Tallinn Pedagogical University. Dissertations on Social Sciences, 14. Tallinn: TPU Press, 2004. 91 p. ISSN 1406-4405. ISBN 9985-58-352-3.

15. ENDEL PÕDER. Role of Attention in Visual Information Processing. Tallinn Pedagogi-cal University. Dissertations on Social Sciences, 15. Tallinn: TPU Press, 2004. 88 p. ISSN 1406-4405. ISBN 9985-58-356-6.

16. MARE MÜÜRSEPP. Lapse tähendus eesti kultuuris 20. sajandil: kasvatusteadus ja lastekirjandus. Tallinna Pedagoogikaülikool. Sotsiaalteaduste dissertatsioonid, 16. Tallinn: TPÜ kirjastus, 2005. 258 lk. ISSN 1406-4405. ISBN 9985-58-366-3.

17. АЛЕКСАНДР ВЕЙНГОЛЬД. Прагмадиалектика шахматной игры: основные осо-бенности соотношения формально- и информально-логических эвристик аргумен-тационного дискурса в шахматах. Таллиннский педагогический университет. Дис-сертации по социальным наукам, 17. Таллинн: Изд-во ТПУ 2005. 74 c. ISSN 1406-4405. ISBN 9985-58-372-8.

18. OVE SANDER. Jutlus kui argumentatiivne diskursus: informaal-loogiline aspekt. Tal-linna Ülikool. Sotsiaalteaduste dissertatsioonid, 18. Tallinn: TLÜ kirjastus, 2005. 110 lk. ISSN 1406-4405. ISBN 9985-58-377-9.

19. ANNE UUSEN. Põhikooli I ja II astme õpilaste kirjutamisoskus. Tallinna Ülikool. Sot-siaalteaduste dissertatsioonid, 19. Tallinn: TLÜ kirjastus, 2006. 193 lk. ISSN 1736-3632. ISBN 9985-58-423-6.

20. LEIF KALEV. Multiple and European Union Citizenship as Challenges to Estonian Citizenship Policies. Tallinn University. Dissertations on Social Sciences, 20. Tallinn: Tal-linn University Press, 2006. 164 p. ISSN 1736-3632. ISBN-10 9985-58-436-8. ISBN-13 978-9985-58-436-1

21. LAURI LEPPIK. Transformation of the Estonian Pension System: Policy Choices and Policy Outcomes. Tallinn University. Dissertations on Social Sciences, 21. Tallinn: Tallinn University Press, 2006. 155 p. ISSN 1736-3632. ISBN 978-9985-58-440-8. ISBN 9985-58-440-6.

22. VERONIKA NAGEL. Hariduspoliitika ja üldhariduskorraldus Eestis aastatel 1940–1991. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 22. Tallinn: TLÜ kirjastus, 2006. 205 lk. ISSN 1736-3632. ISBN 978-9985-58-448-4. ISBN 9985-58-448-1.

23. LIIVIA ANION. Läbipõlemissümptomite ja politseikultuurielementide vastastikustest mõju-dest. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 23. Tallinn: TLÜ kirjastus, 2006. 229 lk. ISSN 1736-3632. ISBN 978-9985-58-453-8. ISBN 9985-58-453-8.

24. INGA MUTSO. Erikooliõpilaste võimalustest jätkuõppeks Eesti Vabariigi kutseõppe-asutustes. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 24. Tallinn: TLÜ kirjastus, 2006. 179 lk. ISSN 1736-3632. ISBN 978-9985-58-451-4. ISBN 9985-58-451-1.

25. EVE EISENSCHMIDT. Kutseaasta kui algaja õpetaja toetusprogrammi rakendamine Eestis. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 25. Tallinn: TLÜ kirjastus, 2006. 185 lk. ISSN 1736-3632. ISBN 978-9985-58-462-0. ISBN 9985-58-462-7.

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26. TUULI ODER. Võõrkeeleõpetaja proffessionaalsuse kaasaegne mudel. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 26. Tallinn: TLÜ kirjastus, 2007. 194 lk. ISSN 1736-3632. ISBN 978-9985-58-465-1.

27. KRISTINA NUGIN. 3-6-aastaste laste intellektuaalne areng erinevates kasvukeskkon-dades WPPSI-r testi alusel. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 27. Tallinn: TLÜ kirjastus, 2007. 156 lk. ISSN 1736-3632. ISBN 978-9985-58-473-6.

28. TIINA SELKE. Suundumusi eesti üldhariduskooli muusikakasvatuses 20. sajandi II poolel ja 20. sajandi alguses. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 28. Tal-linn: TLÜ kirjastus, 2007. 198 lk. ISSN 1736-3632. ISBN 978-9985-58-486-6.

29. SIGNE DOBELNIECE. Homelessness in Latvia: in the Search of Understanding. Tal-linn University. Dissertations on Social Sciences, 29. Tallinn: Tallinn University Press, 2007. 127 p. ISSN 1736-3632. ISBN 978-9985-58-440-8.

30. BORISS BAZANOV. Tehnika ja taktika integratiivne käsitlus korvpalli õpi-treeningprot-sessis. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 30. Tallinn: TLÜ kirjastus, 2007. 95 lk. ISSN 1736-3632. ISBN 978-9985-58-496-5

31. MARGE UNT. Transition from School-to-work in Enlarged Europe. Tallinn University. Dissertations on Social Sciences, 31. Tallinn: Tallinn University Press, 2007. 186 p. ISSN 1736-3632. ISBN 978-9985-58-504-7.

32. MARI KARM. Täiskasvanukoolitajate professionaalsuse kujunemise võimalused. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 32. Tallinn: TLÜ kirjastus, 2007. 232 lk. ISSN 1736-3632. ISBN 978-9985-58-511-5.

33. KATRIN POOM-VALICKIS. Novice Teachers’ Professional Development Across Their Induction Year. Tallinn University. Dissertations on Social Sciences, 33. Tallinn: Tallinn University Press, 2007. 203 p. ISSN 1736-3632. ISBN 978-9985-58-535-1.

34. TARMO SALUMAA. Representatsioonid oranisatsioonikultuuridest Eesti kooli pedagoo-gidel muutumisprotsessis. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 34. Tallinn: TLÜ kirjastus, 2007. 155 lk. ISSN 1736-3632. ISBN 978-9985-58-533-7.

35. AGU UUDELEPP. Propagandainstrumendid poliitilistes ja poliitikavälistes telereklaa-mides. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 35. Tallinn: TLÜ kirjastus, 2008. 132 lk. ISSN 1736-3632. ISBN 978-9985-58-502-3.

36. PILVI KULA. Õpilaste vasakukäelisusest tulenevad toimetuleku iseärasused koolis. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 36. Tallinn: TLÜ kirjastus, 2008. 186 lk. ISSN 1736-3632. ISBN 978-9985-58-578-8.

37. LIINA VAHTER. Subjective Complaints in Different Neurological Diseases – Correla-tions to the Neuropsychological Problems and Implications for the Everyday Life. Tal-linn University. Dissertations on Social Sciences, 37. Tallinn: Tallinn University Press, 2009. 100 p. ISSN 1736-3632. ISBN 978-9985-58-660-0.

38. HELLE NOORVÄLI. Praktika arendamine kutsehariduses. Tallinna Ülikool. Sotsiaal-teaduste dissertatsioonid, 38. Tallinn: TLÜ kirjastus, 2009. 232 lk. ISSN 1736-3632. ISBN 978-9985-58-664-8.

39. BIRGIT VILGATS. Välise kvaliteedihindamise mõju ülikoolile: Eesti kogemuse analüüs. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 39. Tallinn: TLÜ kirjastus, 2009. 131 lk. ISSN 1736-3632. ISBN 987-9985-58-676-1

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40. TIIU TAMMEMÄE. Kahe- ja kolmeaastaste eesti laste kõne arengu tase Reynelli ja HYKS testi põhjal ning selle seosed koduse kasvukeskkonna teguritega. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 40. Tallinn: TLÜ kirjastus, 2009. 131 lk. ISSN 1736- 3632. ISBN 978-9985-58-680-8.

41. KARIN LUKK. Kodu ja kooli koostöö strukturaalsest, funktsionaalsest ning sotsiaalsest aspektist. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 41. Tallinn: TLÜ kirjastus, 2009. 93 lk. ISSN 1736-3632. ISBN 978-9985-58-681-5.

42. TANEL KERIKMÄE. Estonia in the European Legal System: Protection of the Rule of Law Through Constitutional Dialogue. Tallinn University. Dissertations on social sci-ences, 42. Tallinn: Tallinn University Press, 2009. 69 lk. ISSN 1736-3632. 978-9985- 58-673-0.

43. JANNE PUKK. Kõrghariduse kvaliteet ja üliõpilaste edasijõudmine kõrgkoolis. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 43. Tallinn: Tallinna Ülikool, 2010. 124 lk. ISSN 1736-3632. ISBN 978-9985-58-664-8.

44. KATRIN AAVA. Eesti haridusdiskursuse analüüs. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 44. Tallinn: Tallinna Ülikool, 2010. 163 lk. ISSN 1736-3632. ISBN 978-9949-463-18-3.

45. AIRI KUKK. Õppekava eesmärkide saavutamine üleminekul lasteasutusest kooli ning I kooliastmes õpetajate hinnanguil. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid, 45. Tallinn: Tallinna Ülikool, 2010. 175 lk. ISSN 1736-3632. ISBN 978-9949-463-35-0.

46. MARTIN KLESMENT. Fertility Development in Estonia During the Second Half of the XX Century: The Economic Context and its Implications. Tallinna Ülikool. Sotsiaaltea-duste dissertatsioonid, 46. Tallinn: Tallinna Ülikool, 2010. 447 lk. ISSN 1736-3632. ISBN 978-9949-463-40-4.

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DISSERTATSIOONINA KAITSTUD MONOGRAAFIAD, ARTIKLIVÄITEKIRJAD (ilmunud iseseisva väljaandena) 1. TIIU REIMO. Raamatu kultuur Tallinnas 18. sajandi teisel poolel. Monograafia. Tal-

linna Ülikool. Tallinn: TLÜ kirjastus, 2001. 393 lk. ISBN 9985-58-284-5. 2. AILE MÖLDRE. Kirjastustegevus ja raamatulevi Eestis. Monograafia. Tallinna Ülikool.

Tallinn: TLÜ kirjastus, 2005. 407 lk. ISBN 9985-58-201-2. 3. LINNAR PRIIMÄGI. Klassitsism. Inimkeha retoorika klassitsistliku kujutavkunsti kaa-

nonites. I-III. Monograafia. Tallinna Ülikool Tallinn: TLÜ kirjastus, 2005. 1242 lk. ISBN 9985-58-398-1, ISBN 9985-58-405-8, ISBN 9985-58-406-6.

4. KATRIN KULLASEPP. Dialogical Becoming. Professional Identity Construction of Psychology Students. Tallinn: Tallinn University Press, 2008. 285 p. ISBN 978-9985-58-596-2

5. LIIS OJAMÄE. Making choices in the housing market: social construction of housing value. The case of new suburban housing. Tallinn: Tallinn University Press, 2009. 189 p. ISBN 978-9985-58-687-7

ILMUNUD VEEBIVÄLJAANDENA http://e-ait.tlulib.ee/ 1. TIIU TAMMEMÄE. Kahe- ja kolmeaastaste eesti laste kõne arengu tase Reynelli ja

HYKS testi põhjal ning selle seosed koduse kasvukeskkonna teguritega. Tallinna Ülikool. Sotsiaalteaduste dissertatsioonid. Tallinn: Tallinna Ülikooli kirjastus, 2008. 131 lk. ISSN 1736-793X. ISBN 978-9985-58-611-2.

2. KARIN LUKK. Kodu ja kooli koostöö strukturaalsest, funktsionaalsest ning sotsiaalsest aspektist. Tallinn University. Sotsiaalteaduste dissertatsioonid. Tallinna Ülikool. Sot-siaalteaduste dissertatsioonid. Tallinn: Tallinna Ülikooli kirjastus, 2008. 93 lk. ISSN 1736-793X. ISBN 978-9985-58-611-2.

3. MARTIN KLESMENT. Fertility Development in Estonia During the Second Half of the XX Century: The Economic Context and its Implications. Tallinna Ülikool. Sotsiaal-teaduste dissertatsioonid, 46. Tallinn: Tallinna Ülikool, 2010. 447 lk. ISSN 1736-3632. ISBN 978-9949-463-40-4.

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