Abstract
BackgroundCommunity and clinical data have suggested there is an association between trauma exposure and suicidal behavior (i.e., suicide ideation, plans and attempts). However, few studies have assessed which traumas are uniquely predictive of: the first onset of suicidal behavior, the progression from suicide ideation to plans and attempts, or the persistence of each form of suicidal behavior over time. Moreover, few data are available on such associations in developing countries. The current study addresses each of these issues.Methodology/Principal FindingsData on trauma exposure and subsequent first onset of suicidal behavior were collected via structured interviews conducted in the households of 102,245 (age 18+) respondents from 21 countries participating in the WHO World Mental Health Surveys. Bivariate and multivariate survival models tested the relationship between the type and number of traumatic events and subsequent suicidal behavior. A range of traumatic events are associated with suicidal behavior, with sexual and interpersonal violence consistently showing the strongest effects. There is a dose-response relationship between the number of traumatic events and suicide ideation/attempt; however, there is decay in the strength of the association with more events. Although a range of traumatic events are associated with the onset of suicide ideation, fewer events predict which people with suicide ideation progress to suicide plan and attempt, or the persistence of suicidal behavior over time. Associations generally are consistent across high-, middle-, and low-income countries.Conclusions/SignificanceThis study provides more detailed information than previously available on the relationship between traumatic events and suicidal behavior and indicates that this association is fairly consistent across developed and developing countries. These data reinforce the importance of psychological trauma as a major public health problem, and highlight the significance of screening for the presence and accumulation of traumatic exposures as a risk factor for suicide ideation and attempt.
Highlights
Suicidal behavior is an important public health problem that results in significant morbidity and mortality and is a major contributor to the global burden of disease [1,2]
Our main findings were that: (1) in multivariate models there is a strong association between sexual and interpersonal violence and suicide ideation/attempt; (2) there is a dose-response relationship between the number of traumatic events experienced and the subsequent odds of suicide ideation/attempt, but the effects are subadditive with a decay in the strength of the association with more events; (3) specific traumatic events are useful in predicting suicide ideation, they are generally less useful in predicting the progression from suicide ideation to attempt; and (4) the general pattern of findings holds true across high, middle, and low-income countries, regardless of the presence of PTSD, and are not mediated by the presence of mental disorders
The finding that many other traumas are associated with suicidal behavior in bivariate but not multivariate models underscores the complexity of the associations between traumatic events and suicidal behavior
Summary
Suicidal behavior (i.e, suicide ideation, plans, or attempts) is an important public health problem that results in significant morbidity and mortality and is a major contributor to the global burden of disease [1,2]. Psychiatric disorders are among the strongest predictors of suicidal behavior [9,10]; recent data from the World Mental Health Surveys indicate that 31–57% of suicide attempts are not associated with prior psychiatric disorder [11], highlighting the need to understand what other factors might increase the risk of suicidal behavior. Community and clinical data have suggested there is an association between trauma exposure and suicidal behavior (i.e., suicide ideation, plans and attempts).
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