Ausiralian and New Zealand Journal of Psychiatry (1978) 12: 175

AUSTRALASIAN SUICIDOLOGY *

by JOHN S. B. LINDSAY

**

SYNOPSIS A survej has been made of 38 studies of Australasian medical and hospital experiences with attempted and completed suicide in the last decade. The range and depth of the data recorded in the 38 studies have been analysed and reported together with comments on some other multivariate studies from overseas. The implications of these studies for the current medical views about attempted and completed suicide (are they two distinct types or do the) lie on a continuum?) are discussed within a framework relating to the views about suicide that are embedded in our culture.

1NTROl)UCTlON The study of suicide has intrigued scholars and experts in many fields. Anthropologists, philosophers, physicians, psychologists, psychiatrists, sociologists, theologians and others habe all been concerned. The subject is, in fact, so complex that many have concentrated on particular aspects, empliasising either characteristics of the suicide victim, or conditions that distinguish social environments or populations with high o r low suicide rates. Thc distinction bet\\een the general case (e.g., the statistics dealing \kith rates) and the individual person in and out of his aorld is neccs5ary and self-evident. Any general theory must bc bipolar, and relate to the general social relations of a population and the specific disruption of social relations for those ho attempt and/or complete suicide. I t may be, as Martin (1968)suggests, that as psychiatrists move from a biological orientation to a social psychiatry and sociologists concern themselves more with the social past of the victims, gonie rapprochemcnt and bridging theoretical notions \\ill emerge. In this papcr the contributions to the study of attempted or complctcd suicide emanating from Awtralasian medical and hospital cxperiences in the lart decade will be reviewed ”

Kccct\cd I 0 Juiic. 1‘)7X

sr:t’r)chiatri\t

in charge, Townsville General Hospital, North Queensland

and analysed. Thirty-eight studies are available, 26 for attempted and 12 of completed suicide. The completed suicide studies are based on coroners’ records for 7140 deaths, but the attempted suicide material relates to hospital admissions in 12 series, casualty departnicnts in seven studies and also includes outpatient services in two papers with a total of 21,779 patients. 13,844 of these and 3761 deaths are in one paper by Kraus (1975).

Certain data regularly appear: ( I ) The size of the sample, dates of survey, and size of catchment area are recorded usually with a reference t o rates and sometimes a comparison with rates elsewhere.

(2) Age and sex are always referred to but with varying degrees of detailed analysis into age and sex specific rates and ratios. (3) All but three made some specific reference t o method either by studying overdoses only as in eight papers, o r specifying the percentage of drug overdoses in 10 papers (mean = 82.32% for attempted, 35.68% for completed), or giving more specific detail about the various methods actually used.

At that point the overall consistency of reporting ends. Some writers were clearly intent on developing studies in depth for one or a few variables, while others were anxious to give a broader view. The demographic variables specified are recorded in Table 1. TABLE 1 Attempted

Completed

12 times 8 times

5 times

-

Civil status Occupation % or other) unemployed(as Migrant status Religion Social class Education

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6 times 4 times 3 times 3 times

n = 26

nil 2 times once 2 times nil n=12

AUSTRALASIAN SUICI~~LOGY

TABLE 2 Attempted 1. Previous history of 2.

3. 4. 5.

6.

I.

attempts Association with alcohol/ism Currently attending a doctor Psychiatric diagnosis Pregnancy Presence of physical illness Death rate

times 9 times times

6 times 2 times times

9 times

Completed

upon the total incidence of the phenomenon in the community, and only measure the need for hospital admission.

once 3 times 4 times 4 times

2 times once nil

Medically orientated variables were reported in Table 2. For attempted suicide the day of the week was recorded in five studies and the month or season in five. For completed suicide this occurred once and twice. In these reported case studies there is a good degree of consensus over the findings for the variables noted above, and the results show that suicide rates increase by age and attempts decrease, that female attempts exceed male and male completed exceed female; that married persons have a lower suicide rate than single, widowed, or divorced, and that suicide rates are highest in the most and the least prestigious occupations. Suicide rates are higher for Protestants and lower for Catholics; rates may be higher in minority or migrant groups, but this varies according to the time and place in question. There is little agreement about the time of day and the day of the week, but some for the month in the year (Spring or early Summer).

SMALLER SOCIAL GROUPINGS Other social factors relate to smaller social groupings, local communities, neighbourhoods, social networks, housing estates, etc. With much smaller units it is possible to make comparisons between the rates of suicide and other forms of socially disturbing behaviour in different areas. Social areas analysts use suicide, alcoholism, etc., amongst others, as suitable indicants to measure and define what are the different social areas. In their comprehensive paper, Edwards et al (1968) made observations about the area of domicile of each patient admitted to hospital after attempted suicide. They give rates, varying from 1.5 to 41.6 per 10,OOO, for the central city areas, isolated townships, and peripheral suburbs. The distribution of attempted suicides in Brisbane reveals predominantly high rates in the central area, a finding which is more o r less expected, and high rates in the growing suburbs on the periphery of the city. These two areas contained just over a quarter of the population and account for half of the attempted suicides. They tentatively suggest that isolation and comparative lack of established conimunity facilities play a part in the production of these high attempted suicide rates in the periphery of the city. I t is not quite clear how they measured “suburban isolation”, but they argue that most of the residents in the new suburbs have lived there for only a short period of time. The positive correlation niight be with “social mobility”.

A substantial proportion of suicide victims varying from

13%-24% were reputedly ill physically, From 25V0-74~/n had been under some sort of medical care and up to 33% were receiving psychiatric care. Excessive drinking and suicide were frequently associated (male 13%-52%; female 9%-16%) and specifically studied by Koller and Castanos ( 1968).

SOCIAL FACTORS Difficulty arises when attention is moved to the social and interpersonal environment. Some of the social factors refer to the total society (e.g., social class) and are established concepts derived from a number of measurable indicants. Burvill (1971) gives a classification into social class for male rural and urban completed suicides based on the Western Australia registrar general classification. He notes tlie complete absence of any female suicides among the single, the separated, and the divorced outside the metropolitan area of Perth. This leads on to considerations of those who live alone, and so to the concept of “social isolation”. Edward et al(l968) also make some comments about social class and attempted suicide. They note that the previous workers have argued that upper social classes are underrepresented by concealment or reluctance on the part of the patient to seck hospital treatment. Surveys of attempted suicides based on hospital admissions throw little light

INTERPERSONAL ENVIRONMENT When the interpersonal environment of the event is studied there are judgements made about precipitating events in 10 papers for attempted and three for completed suicide. Buckle, McConaghy and Linnane (1965) have looked at both immcdiate precipitating and historical determinants. They d o not see a direct relationship between parental deprivation, an indicator of a disturbed parent-child relationship, and subsequent suicidal attempts, but point out that other environmental factors may become significant as a result of parental deprivation. Their findings, in the directions expected, d o not reach the usual levels of statistical significance. Koller and Castanos (1968a) have reported a controlled study. There is still considerable dispute about tlie relationship of parental deprivation and psychiatric disorder. These disruptions of social and interpersonal relations are seen as important in contemporary psychiatric reports. There is frequently a lack. of definition for terms such as marital discord, faniily disharrnony, o r serious interpersonal conflict. Thus (for attempted suicides) Oliver (1971) proportions 21 V o to serious interpersonal conflict, 15% to marital discord. and 14(%’11to the faniily disharmony.

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JOHN

S.B. LINDSAY

Edwards et al (1968) give a broader spectrum. They have sexual traumas, disputes, and rejections (9% and 8% for male and female). Interpersonal disputes sum to 40.5% (male) and 61% (female). These latter are subdivided into disputes with (a) parents, (b) siblings, (c) spouse, and (d) other persons. They continue with bereavements (2% and ITo), financial worries (18% and 12%), housing problems (0.5%), unemployment (6.5010 and 1 To), physical illness (4% and 2.5%), and multiple(l5.5% and 10%). Nearer the time of the act there are observations that no contact was made with available family, social, professional, or voluntary helpers. It is perhaps a little eas: to move from a statement that a patient did not contact anyone in a help-seeking capacity to more abstract notion of “social isolation”. Some attempts at suicide occur in isolation and some occur in an interpersonal situation. lsolation (or otherwise) for completed suicide was referred to by five writers.

MULTIVARIATE STUDIES Farberow and Schneidman’s ( I 961) bibliography cites works referring to hundreds of variables considered as correlated with, or “causes” of, suicide. The list refers to abortion (3 times), alcoholism (26 times), climate (6 times), depressive states ( I 1 times), drug addiction (5 times), epilepsy (9 times), hereditary (8 times), Huntington’s chorea (3 times), impulse (7 times), insanity (76 times), menstruation (7 times), obsession or compulsion (6 times), pathological anatomy (9 times). pregnancy (4 times), schizophrenia (9 times), sex and its perversions (7 times), the weather (10 times), and so on; many others are referred 10 only once or twice. Many of the variables that correlate with suicide were identified in the 19th Century. Positive correlations with rapid social change, economic depression, higher social economic position, in urban areas, with Protestantism were

TABLE 3 Correlation Coefficients (Rho) lndicants Attempted suicide Much overcrowding High Divorced rate Low rate adolescent psychiatric referral High rate juvenile delinquency Referral to R.S.S.P.C.C. Adolescent attempts at

Completed

+ 709

725 (398) 68 7 612 (538)

Attempted

770 (527) -

336 (122)

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established by mid-century and the variation by age, sex, marital status, time of year, day of week, and time of day was reviewed by Morselli in 1879. Sainsbury (1955) and Stengel (1 964) have confirmed the continued significance of these and Stengel has emphasised what is not common to attempted and completed suicide. There are available some other studies which attempt to measure the differences. McCulloch, Philip and Carstairs (1967) surveyed the relationships between consecutive suicides and 32 social variables in the Edinburgh urban wards. Similar data for attempted suicide were recorded by Philip and McCulloch (1966). They carried out a correlation study and the significant variables are noted in Table 3. Using these figures and particularly the correlation of + 0.709 between attempted and completed suicide, first order partial coefficients have been calculated and are given in brackets in Table 3. It is clear that there is still a good deal in common; but some differences between attempted and completed became more apparent. The variables particularly relating to children cease to be significant for completed suicide. Other non-significant variables studied included one person dwelling, old age pensioners, immigrants, road accidents, infant mortality, telephone vandalism, and other measures of minor conflict with the law, e.g., eviction notices, rent arrears, peace warnings, etc. They seem to be built round a common theme that might be related to unhappy home life. In another study, Schmid (1960) surveyed 35,000 offences in the Seattle area census tracts. Included in these were the completed and attempted suicides. That attempted suicides should be treated as an offence makes the data much more biased. The correlation between attempted and completed suicide was + 0.600, and the coefficients for attempted and completed suicides with other social variables were the same -t 0.100, except for a “percentage male” and “percentage changed residence”. These results imply that the populations are identical and perhaps only record the fact that it is the offence of either attempting or completing suicide that is being examined. Pokorny (19651, in a study of human violence, compared homicide and aggravated assault with suicide and attempted suicide using 1960 material from Houston Police Department and 120 census tracts. He found a positive correlation of + 0.425, between suicide (“-294) and suicide attempts (”‘287). There was no significant correlation between suicide and homicide through these census tracts.

The close association between attempted and completed suicides throughout all these analyses conflicts with the current arguments that attempted suicide occurs in a difsuicide ferent population from completed suicide. It is also clear High density of that the two populations do have some overlap as some of 507 pop ukdt ion the attempted suicides could have easily completed the Many children in care 858 (812) 523 (-234) event save for some fortuitous arrival of some other perMany school absences 642 (468) 503 (089) Many tenement houses 487 son on the scene. Stengel (1964) refers to this and gives a 46 Owner occupied houses 4 18 (-197) 4 1 0 (-181) table relating to “Agents intervening”, which shows about 40Vo of the attempts remained attempts, because of the acZero and first order correlation between various cidental intervention of either a special person or others. indicants and suicide (dttcmptcd andDownloaded complrted). from anp.sagepub.com at Monash University on June 22, 2015 606 (075) 594 (-073) 576 (370)

81 1 (679) 874 (798) 493 (147)

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AUSTKAI.ASIAN SUlClDol.OGY

COMMENT There appear to be two separate approaches, one emphasising the differences between attempted and completed suicide and the other arguing a continuum from suicidal thoughts, to suicidal threats, to suicidal attempts and, finally, completed suicide. In the continuum view the common features are made more relevant. There are perhaps additional items that should be included on the continuum. There is little information about those who remain undetected after an unsuccessful suicide attempt. Nor d o we know how often suicidal thoughts are experienced but not communicated. That some attempt to communicate suicide intention before the event is well recognised but the message may fall on deaf ears. Surrounding these two medical positions is a popular folk lore, and Whitlock (1971)refers to the attitudes towards suicide that are part of the nation’s culture. On a continuum theory some of the suicide culture will attend events without fatal outcome. There will also be cultural folklore determinants relating to attempted suicide as such. Kreitman et al (1970)have made an interesting study of attempted suicidal behaviour within family settings. They studied a series of 135 suicidal attempts and for each the names of kin and close friends together with age, addresses and their length of stay at that address. His total population at risk then consisted of 578 individuals who might be expected to have 4.23 suicidal attempts in the time of the survey. In fact, 17 numbers of this contact population were admitted. Similar results have been obtained in Auckland following the families of 44 attempted suicides (Lindsay and Nathan (1974)). The figures support their arguments that many so called “suicidal attempts” act as a form of communication between the patient and the key figures in his environment. They argue that there is a sub-culture in contemporary society in which the communicational functions of attempted suicide are particularly well defined. The reported series of papers mainly record hospital events. Edwards et al(l968) comment that they intended to carry out a follow-up study of their cohort and, as with two other studies of both attempted and completed suicide, they noted that a few attempters ended up in the completed series. Whitlock (1974) reports that he found the cohort follow-up was quite impossible, as far too many persons either had left their former addresses or simply were unwilling to participate in any further investigations. A partial follow-up of patients who were pregnant and had made suicidal attempts was recorded by Whitlock and Edwards (1968).Other patients’ outcome events noted in six papers are hospital orientated and refer to “disposal”.

medical concerns in Table 2. The relative importance given to recent or current medical care, particularly for completed suicide, indicates a professional concern with selfinflicted death or attempts thereat. A suicide attempt, succesful or not, presents a situation to the doctor that differs significantly, as regard the wish to live, from other medical presentations. The papers surveyed agree in their simple specification of the patient and vary in the degree they have explored additional data for the presenting patient. A few papers (e.g. Edwards et al (1968) are exemplary in the variety and sophistication of the additional data they provide to ident i f y the patient both in his microsocial environment and niacrosocial situation. The majority are concerned more with the act than the actors, the here and now presentation of the actor more than the actor’s future, their own perception of the situation rather than the patient’s unhappy perception of his social world, including events leading up to his present state and that present state itself. Do these attitudes really reflect the nation’s cultural attitudes towards suicide, attempted or completed? How much d o cultural views reflect the level of care and concern that doctors evidence towards such patients at a microsocial level? I s it possible that, by the continued reaffirmation of these norms of suicidal behaviour in a culture, such reaffirmation continues to provide a set of socially determined behaviours including the suicidal act as the key patterns to use in any situation where there is no immediate or apparent other way out’? Kreitman et al (1970)in their study of the family microcosm have demonstrated such an effect i n the sub-culture. Does this apply to the macrocosm, to our overall emotional views about suicide?

REFERENCES Boxall, J. S. and Chauvel, P. J . (1966).Attempted suicide: a review of consecutive cases at a district hospital. Medical .lournal of Australia, 1: 264. Bridges-Webb, C. (1973).Attempted suicide by overdose in a country town. Medical Journal ofAustralia, 2: 782. Buckle, R. C., Linnane, J. and McConaghy, N. (1965).Attempted suicide presenting at the Alfred Hospital, Melbourne. hledical Journal of .4ustralia, I: 754. Burvill, P. W . (1970). Age-sex variations in suicide in Western Australia, 1901-1967. Medical Journal of Ausfralia, 2: I113.

Burvill, P. W. (1970). Methods of suicide in Western Australia. Medical Journal of Australia, 2: 41 1. The papers dealing with attempted suicide describe the hospital routine dealing with those who present with some Burvill, P. W. (1971).Suicide in Western Australia, 1967: self-inflicted state. Such acts confront the normative tradianalysis of coroners’ records. Australian and New tions of medical and hospital care with a paradox. Some of Zealand Journal of Psychiatry, 5: 833. the papers may be attempts to answer the questions, “Who are these patients?” and “What did they do?” A Burvill, P. W. (1975). Attempted suicide in the Perth nian/woman aged 26 years with an overdose/other is acstatistical division, 1971-72. Australian and New ceptable as and given as the simple answer. The further Zealand Journal o f Psychiatry, 9: 213. 1, and specifications given have been recordedDownloaded in Table from anp.sagepub.com at Monash University on June 22, 2015

JOHN S.B. LINDSAY

Campion, D. S. and Spence, M. (1963). Barbiturate intoxication occurring in Auckland. New Zealand Medical Journal, 62: 206. Clifton, B. S., Mackay, K . M. and McLeod, J. G . (1965). Barbiturate poisoning. Medical Journal o f Australia, 1: 53.

Connell, H. &I (1972). . Attempted suicide in school children. Medical Journal of Australia, 1: 686. Diespecker, D. D. (1973). Some characteristics of attempted suicide. Medical Journal o f Australia, 2: 121. Duncan, D. R., O’Gorman, J . G., Fleming, K. J. A. and Solas, R. G . (1974). Suicidal behaviour in the Australian army: incidence, methods and outcome. Medical Journal o fAustralia, 2: 736. Eastwood, M. R., Henderson, A. S. and Montgomery, 1. M . (1972). Personality and parasuicide methodological problems. Medical Journal o f Australia, 1: 170. Edwards, J. E. and Whitlock, F. A. (1968). Suicide and attempted suicide in Brisbane. Medical Journal o f Australia, 1932.

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Kraus, J. (1975). ‘Suicide behaviour’ in New South Wales. British Journal o f Psychiatry, 126: 3 13. Kreitman, H., Smith, P. and Eng-Seong Tan (1970). Attempted suiciders language: a n empirical study. British Journal o f Psychiatry, 116: 465. Krupinski, J., Stoller, A. and Polke, P. (1966-67). Attempted suicides admitted to the Mental Health Department, Victoria, Australia. International Journal of Social Psychiatry, 13: 5 . Krupinski, J., Polke, P. and Stoller, A. (1965). Psychiatric services and attempts and completed suicides in Victoria during 1963. Medical Journal of Australia, 2: 773. Last, P.M. (1967). Attempted suicide. Medical Journal of Australia, 1: 708. Lindsay, J . S. B. (1973). Suicide in the Auckland area. New Zealand Medical Journal. 77: 148. Lindsay, J. S. B. and Nathan, D. (1974). 122 families. New Zealand Medical Journal, 80: 258.

Farberow, N. L. and Schneidman, E. S. (1961). The Cry for Help. McGraw Hill, New York.

Linnane, J., Buckle, R. C. and McConaghy, N. (1966). Comparison of patients seen a t the Alfred Hospital after suicide attempts in 1959-60 and 1963-64. Medical Journal o fAustralia, I: 665.

Finlay-Jones, R. A. and Kidd, C. B. (1972). The clients of the telephone Samaritan service in Western Australia. Medical Journal o fAustralia, I: 690.

McConaghy, N., Linnane, J. and Buckle, R. C. (1966). Parental deprivation and attempted suicide. Medical Journal o fAustralia, 1: 886.

Freeman, J. W., Ryan, C. A. and Beattie, R.R. (1970). Epidemiology of drug overdose in Southern Tasmania. Medical Journal o fAustralia, 2: 669.

McCulloch, J. W., Philips, A . E. and Carstairs, G. M. (1967). The ecology of suicidal behaviour. British Journal o f Psychiatry, 113: 3 !3.

Giddens. A. (1965). The suicide problem in French sociology. British Journal o f Sociology, 16: 3.

Martin, W. T. (1968). Theories of variation in the suicide rate, in Suicide. (Ed. Gibbs, J . P.) Harper & Row, New York.

Gold, N. (1965). Suicide and attempted suicide in North Eastern Tasmania. Medical Journal o f Australia, 2: 361. Goldney, R. D. (1975). Outpatient follow-up of those who have attempted suicide: fact or fantasy. Australian and New Zealand Journal o f Psychiatry, 9: 111.

Medlicott, R. W. and Medlicott, P. A. W. (1969). Suicide in and after discharge from a private psychiatric hospital over a period of 86 years. Australian and New Zealand Journal o f Psychiatry, 3: 137.

Henderson, A. S., Eastwood, h.1. R. and Montgomery, I. M. (1972). Self-poisoning in Edinburgh and Hobart: a comparison. Social Psychiatry, 7: 30.

Mills, J., Williams, C., Sale, I., Perkins, G. and Henderson, S. (1974). The epidemiology of self-poisoning in Hobart, 1968-72. Australian and New Zealand Journal o f Psychiatry, 8: 167.

James, I . P., Derham, S. P. and Scott-Orr, D. N. (1963). Attempted suicide. Medical Journal of’Australia, 1: 375.

Morselli, E. (1879). IISuicideo. Milan - cited by Giddens.

Ironside, M’. (1969). Iatrogenic contributions to suicide and a report on 37 suicide attempts. New Zealand Medical Journal, 68: 207. Koller, K. M. and Castanos, J . N. (1968a). The influence of childhood deprivation i n attempted suicides. Medical Journal of‘Australia,I : 396. Koller, K . M . , and Castanos, J.N. (1968b). Attempted suicide and alcoholism. Aledical Journal of Australia, 2: 835.

Oliver, R. G., Kaminski, Z., Tudor, K. and Hetzel, B. S. (1971). The epidemiology of attempted suicide as seen in the casualty department, Alfred Hospital, Melbourne. Medical Journal ofAustralia. 1: 883. Phillips, A. E. and McCulloch, J. W. (1966). Use of social indices in psychiatric epidemiology. Briti.sh Journal o f Prer,entiveand Social Medicine, 20: 122. Pokorny, A. D. (1965). Human violence, in Suicide. (Ed. Gibbs, J.P.). Harper B Row, London.

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AUSTRALASIAN SUI~IDOL~GY

Sainsbury, P. (1965). Suicide in London. Chapman and Hall, London.

Werry, J. S . and Pedder, J . (1976). Self-poisoning in Auckland. New Zealand Medical Journal, 82: 183.

Saint, E. G. (1965). Suicide in Australia. Medical Journal ofAustralia, 1: 91 I .

Whitlock, F. A. (1971). Migration and suicide. Medical Journal o f Australia, 2: 840.

Schmid, C. R. (1960). Urban crime areas. American Sociological Review, 25: 530 and 655.

Whitlock, F. A. (1974). Personal communication.

Stengel, E. (1964). Suicide and Attempted Suicide. Penguin Books. M iddlesex. Wendling, A. and Polk, K. (1958). Suicide and social areas. Pacific Social Review. 1: 50.

Reprint requests to: Dr. J.S.B. Lindsay Townsville General Hospital Townsville North Queensland 4810

Whitlock, F. A. (1975). Suicide in Brisbane, 1956-73: the drug-death epidemic. Medical Journal of Australia, 1: 737.

Whitlock, F. A. and Edwards, J. E. (1968). Pregnancy and attempted suicide. Comprehensive Psychiatry, 9: 1 .

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Australasian suicidology.

Ausiralian and New Zealand Journal of Psychiatry (1978) 12: 175 AUSTRALASIAN SUICIDOLOGY * by JOHN S. B. LINDSAY ** SYNOPSIS A survej has been mad...
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