Contributors to suicidality in rural communities: beyond the effects of depression

Tonelle E Handley,John R Attia,Frances J Kay-Lambkin,Terry J Lewin,Michael Fitzgerald,Kerry J Inder,Brian J Kelly,Helen J Stain

doi:10.1186/1471-244x-12-105

Abstract

BackgroundRural populations experience a higher suicide rate than urban areas despite their comparable prevalence of depression. This suggests the identification of additional contributors is necessary to improve our understanding of suicide risk in rural regions. Investigating the independent contribution of depression, and the impact of co-existing psychiatric disorders, to suicidal ideation and suicide attempts in a rural community sample may provide clarification of the role of depression in rural suicidality.Methods618 participants in the Australian Rural Mental Health Study completed the Composite International Diagnostic Interview, providing assessment of lifetime suicidal ideation and attempts, affective disorders, anxiety disorders and substance-use disorders. Logistic regression analyses explored the independent contribution of depression and additional diagnoses to suicidality. A receiver operating characteristic (ROC) analysis was performed to illustrate the benefit of assessing secondary psychiatric diagnoses when determining suicide risk.ResultsDiagnostic criteria for lifetime depressive disorder were met by 28% (174) of the sample; 25% (154) had a history of suicidal ideation. Overall, 41% (63) of participants with lifetime suicidal ideation and 34% (16) of participants with a lifetime suicide attempt had no history of depression. When lifetime depression was controlled for, suicidal ideation was predicted by younger age, being currently unmarried, and lifetime anxiety or post-traumatic stress disorder. In addition to depression, suicide attempts were predicted by lifetime anxiety and drug use disorders, as well as younger age; being currently married and employed were significant protective factors. The presence of comorbid depression and PTSD significantly increased the odds of reporting a suicide attempt above either of these conditions independently.ConclusionsWhile depression contributes significantly to suicidal ideation, and is a key risk factor for suicide attempts, other clinical and demographic factors played an important role in this rural sample. Consideration of the contribution of factors such as substance use and anxiety disorders to suicidal ideation and behaviours may improve our ability to identify individuals at risk of suicide. Acknowledging the contribution of these factors to rural suicide may also result in more effective approaches for the identification and treatment of at-risk individuals.

Highlights

Rural populations experience a higher suicide rate than urban areas despite their comparable prevalence of depression
Of the 2639 Australian Rural Mental Health Study (ARMHS) participants recruited, 867 were selected for Composite International Diagnostic Interview (CIDI) interview based on their K10 score, and 230 (27%) participants declined, 637 (73%)
Our findings revealed that approximately one-third of individuals with lifetime suicide attempts and over one-third of individuals with lifetime suicidal ideation did not have a history of depressive disorder, providing support for the emerging theory of these conditions as separable states

Summary

Introduction

Rural populations experience a higher suicide rate than urban areas despite their comparable prevalence of depression. This suggests the identification of additional contributors is necessary to improve our understanding of suicide risk in rural regions. Prior suicidal ideation or suicide attempts are the primary risk factors for future suicidal behaviours [1,2]. A recent international study found that across a variety of countries and urban/rural localities, suicidal ideation occurred more frequently than depression [7]. Evidence from psychological autopsy studies shows that approximately onethird of suicide victims do not have symptoms indicative of major depression at their time of death [10], suggesting the importance of other contributory factors in a substantial proportion of those who die by suicide

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