1

TALLINNA ÜLIKOOL
SOTSIAALTEADUSTE DISSERTATSIOONID

TALLINN UNIVERSITY
DISSERTATIONS ON SOCIAL SCIENCES

47
















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
5
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
6
KOKKUVÕTE ...................................................................................................................... 52
REFERENCES ...................................................................................................................... 55
APPENDIXES ...................................................................................................................... 99
ELULOOKIRJELDUS ........................................................................................................ 163
PUBLIKATSIOONID ......................................................................................................... 164
CURRICULUM VITAE ..................................................................................................... 170
PUBLICATIONS ................................................................................................................ 171

7
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.
8
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.
9
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.
10
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.
11
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.



12
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-
13
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.
14
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).
15
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
16
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
17
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-
18
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, 10
th
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
N
o
n
-
f
a
t
a
l

o
u
t
c
o
m
e

I
n
t
e
n
t
i
o
n
a
l

(
d
e
l
i
b
e
r
a
t
e
)

s
e
l
f
-
i
n
f
l
i
c
t
i
o
n

S
e
l
f
-
h
a
r
m

(
i
n
j
u
r
y
,

p
o
i
s
o
n
i
n
g
)

N
o
n
-
h
a
b
i
t
u
a
l

b
e
h
a
v
i
o
u
r

I
n
t
e
n
t
i
o
n

t
o

d
i
e

D
e
s
i
r
e

t
o

e
v
o
k
e

c
h
a
n
g
e
s

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
21
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).
25
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.



27
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).
28
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
30
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.
32
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

33
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
34
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
35
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.
36
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
37
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-
38
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.
39
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).
40
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).


41
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
42
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).
43
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
44
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
45
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
46
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,
47
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).
48
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-
49
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).

50
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
51
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.

52
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
53
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-
54
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.
55
REFERENCES
AAS/SPRC (2006). The language of suicide. Core competencies for the assessment and
management of individuals at risk for suicide. Washington, DC: American Asso-
ciation of Suicidology/ Suicide Prevention Resource Center.
Aish, A. M. and Wasserman, D. (2001). Does Beck's Hopelessness Scale really measure
several components? Psychological Medicine, 31(2): 367-372.
Andriessen, K. (2006). On "intention" in the definition of suicide. Suicide and Life-
Threatening Behavior, 36(5): 533-538.
Awata, S., Bech, P., Koizumi, Y., Seki, T., Kuriyama, S., Hozawa, A., Ohmori, K., Nakaya,
N., Matsuoka, H. and Tsuji, I. (2007). Validity and utility of the Japanese version
of the WHO-Five Well-Being Index in the context of detecting suicidal ideation in
elderly community residents. International Psychogeriatrics, 19(1): 77-88.
Beautrais, A. L. (2001). Suicides and serious suicide attempts: two populations or one?
Psychological Medicine, 31(5): 837-845.
Bech, P. and Awata, S. (2009). Measurement of suicidal behaviour with psychometric
scales. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspec-
tive. D. Wasserman and C. Wasserman (Eds.). Oxford, UK: Oxford University
Press: 305-311.
Bech, P., Olsen, L. R., Kjoller, M. and Rasmussen, N. K. (2003). Measuring well-being
rather than the absence of distress symptoms: a comparison of the SF-36 Mental
Health subscale and the WHO-Five Well-Being Scale. International Journal of
Methods in Psychiatric Research, 12(2): 85-91.
Bech, P., Raabaek Olsen, L. and Nimeus, A. (2001). Psychometric scales in suicide risk
assessment. Suicide: An unnecessary death. D. Wasserman (Ed.). London: Martin
Dunitz: 147-157.
Beck, A. T., Kovacs, M. and Weissman, A. (1975). Hopelessness and suicidal behavior. An
overview. JAMA, 234(11): 1146-1149.
Beck, A. T., Kovacs, M. and Weissman, A. (1979). Assessment of suicidal intention: the
Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology, 47(2):
343-352.
Beck, A. T., Schuyler, D. and Herman, I. (1974a). Development of Suicidal Intent Scales.
The Prediction of Suicide. A. T. Beck, H. L. P. Resnick and D. J. Lettieri (Eds.).
Bowie, Maryland: Charles Press: 45-56.
Beck, A. T., Steer, R. A., Beck, J. S. and Newman, C. F. (1993). Hopelessness, depression,
suicidal ideation, and clinical diagnosis of depression. Suicide and Life-
Threatening Behavior, 23(2): 139-145.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. and Erbaugh, J. (1961). An inventory for
measuring depression. Archives of General Psychiatry, 4: 561-571.
Beck, A. T., Weissman, A., Lester, D. and Trexler, L. (1974b). The measurement of pessi-
mism: the hopelessness scale. Journal of Consulting and Clinical Psychology,
42(6): 861-865.
Berger, P. L. and Luckmann, T. (1966/1991). The social construction of reality: a treatise in
the sociology of knowledge. London: Penguin Books.
Bertolote, J. M. and Fleischmann, A. (2002). A global perspective in the epidemiology of
suicide. Suicidologi, 7(2): 6-7.
Bertolote, J. M., Fleischmann, A., De Leo, D., Bolhari, J., Botega, N. J., De Silva, D., Tran
Thi Thanh, H., Phillips, M., Schlebusch, L., Varnik, A., Vijayakumar, L. and
Wasserman, D. (2005). Suicide attempts, plans, and ideation in culturally diverse
56
sites: the WHO SUPRE-MISS community survey. Psychological Medicine, 35(10):
1457-1465.
Bertolote, M. J. (2001). Suicide in the world: an epidemiological overview 1959-2000. Sui-
cide: An Unnecessary Death. D. Wasserman (Ed.). London: Martin Dunitz: 3-10.
Bertolote, M. J. (2009). A global perspective on the magnitude of suicide mortality. Oxford
Textbook of Suicidology and Suicide Prevention: A Global Perspective. D.
Wasserman and C. Wasserman (Eds.). Oxford, UK: Oxford University Press: 91-
98.
Bertolote, M. J., Fleischmann, A., De Leo, D. and Wasserman, D. (2009). Suicidal thoughts,
suicide plans and attempts in the general population on different continents. Oxford
Textbook of Suicidology and Suicide Prevention: A Global Perspective. D.
Wasserman and C. Wasserman (Eds.). Oxford, UK: Oxford University Press: 99-
104.
Bertolote, M. J. and Wasserman, D. (2009). Development of definitions of suicidal behav-
iours: from suicidal thoughts to completed suicides. Oxford Textbook of Suicidol-
ogy and Suicide Prevention: A Global Perspective. D. Wasserman and C.
Wasserman (Eds.). Oxford, UK: Oxford University Press: 87-90.
Bolz, W. (2002). Psychological analysis of the Sri Lankan conflict culture with special refer-
ence to the high suicide rate. Crisis, 23(4): 167-170.
Bonsignore, M., Barkow, K., Jessen, F. and Heun, R. (2001). Validity of the five-item WHO
Well-Being Index (WHO-5) in an elderly population. European Archives of Psy-
chiatry and Clinical Neuroscience, 251 Suppl 2: II27-31.
Botega, N. J., de Azevedo Barros, M. B., de Oliveira, H. B., Dalgalarrondo, P. and Marin-
Leon, L. (2005). Suicidal behavior in the community: prevalence and factors asso-
ciated with suicidal ideation. Revista Brasileira de Psiquiatria, 27(1): 45-53.
Bowles, J. R. (1995). An example of a suicide prevention program in a developing country.
Preventive Strategies on Suicide. R. F. W. Diekstra, W. Gulbinat, I. Kienhorst and
D. De Leo (Eds.). Leiden: Brill: 173-206.
Bray, I. and Gunnell, D. (2006). Suicide rates, life satisfaction and happiness as markers for
population mental health. Social Psychiatry and Psychiatric Epidemiology, 41(5):
333-337.
Breault, K. D. (1986). Suicide in America: A test of Durkheim's theory of religious and
family integration, 1933-1980. American Journal of Sociology: 628-656.
Colucci, E. and Martin, G. (2008). Religion and spirituality along the suicidal path. Suicide
and Life-Threatening Behavior, 38(2): 229-244.
da Silva, V. F., de Oliveira, H. B., Botega, N. J., Marin-Leon, L., de Azevedo Barros, M. B.
and Dalgalarrondo, P. (2006). [Factors associated with suicidal ideation in the
community: a case-control study]. Cadernos de Saúde Pública, 22(9): 1835-1843.
De Leo, D., Burgis, S., Bertolote, J., Kerkhof, A. and Bille-Brahe, U. (2004). Definitions of
Suicidal Behaviour. Suicidal Behaviour: Theories and Research findings. D. De
Leo, U. Bille-Brahe, A. Kerkhof and A. Schmidtke (Eds.). Göttingen: Hogrefe &
Huber: 17-41.
Denning, D. G., Conwell, Y., King, D. and Cox, C. (2000). Method choice, intent, and gen-
der in completed suicide. Suicide and Life-Threatening Behavior, 30(3): 282-288.
Dervic, K., Oquendo, M. A., Grunebaum, M. F., Ellis, S., Burke, A. K. and Mann, J. J.
(2004). Religious affiliation and suicide attempt. The American Journal of Psychia-
try, 161(12): 2303-2308.
Diekstra, R. F. (1993). The epidemiology of suicide and parasuicide. Acta Psychiatrica
Scandinavica. Supplementum, 371: 9-20.
57
Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95(3): 542-575.
Diener, E. and Lucas, R. E. (2000). Subjective Emotional Well-Being. Handbook of emo-
tions. M. Lewis and J. M. Haviland-Jones (Eds.). New York: Guilford Press: 325-
337.
Douglas, J. D. (1967). The social meanings of suicide. Princeton, N.J.: Princeton University
Press.
Duberstein, P. R., Conwell, Y., Conner, K. R., Eberly, S., Evinger, J. S. and Caine, E. D.
(2004). Poor social integration and suicide: fact or artifact? A case-control study.
Psychological Medicine, 34(7): 1331-1337.
Durkheim, É. (1897/2002). Suicide: A Study in Sociology. London and New York:
Routledge Classics.
Dyer, J. A. and Kreitman, N. (1984). Hopelessness, depression and suicidal intent in para-
suicide. The British Journal of Psychiatry, 144: 127-133.
Eddleston, M. (2000). Patterns and problems of deliberate self-poisoning in the developing
world. QJM: Monthly Journal of the Association of Physicians, 93(11): 715-731.
Eddleston, M. and Phillips, M. R. (2004). Self poisoning with pesticides. British Medical
Journal, 328(7430): 42-44.
Ellison, C. G., Burr, J. A. and McCall, P. L. (1997). Religious Homogeneity and Metropoli-
tan Suicide Rates. Social Forces, 76(1): 273-299.
Farberow, N. L. and Shneidman, E. S. (1961). The cry for help. New York: Blakiston Divi-
sion.
Faria, N. M., Victora, C. G., Meneghel, S. N., de Carvalho, L. A. and Falk, J. W. (2006).
Suicide rates in the State of Rio Grande do Sul, Brazil: association with socioeco-
nomic, cultural, and agricultural factors. Cadernos de Saúde Pública, 22(12): 2611-
2621.
Farmer, R. D. (1988). Assessing the epidemiology of suicide and parasuicide. The British
Journal of Psychiatry, 153: 16-20.
Flannelly, K. J., Ellison, C. G. and Strock, A. L. (2004). Methodologic issues in research on
religion and health. The Southern Medical Journal, 97(12): 1231-1241.
Fleischmann, A., Bertolote, J. M., De Leo, D., Botega, N., Phillips, M., Sisask, M., Vijaya-
kumar, 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. Psy-
chological Medicine, 35(10): 1467-1474.
Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Bolhari, J., Botega, N. J., De
Silva, D., Phillips, M., Vijayakumar, L., Varnik, A., Schlebusch, L. and Thanh, H.
T. (2008). Effectiveness of brief intervention and contact for suicide attempters: a
randomized controlled trial in five countries. Bulletin of the World Health Organi-
zation, 86(9): 703-709.
Fleischmann, A., Bertolote, M. J., De Leo, D. and Wasserman, D. (2009). Instruments used
in SUPRE-MISS. Oxford Textbook of Suicidology and Suicide Prevention: A
Global Perspective. D. Wasserman and C. Wasserman (Eds.). Oxford, UK: Oxford
University Press: 313-316.
Giddens, A. (1991/2004). Modernity and self-identity: self and society in the late modern
age. Cambridge: Polity.
Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M. and Bunney, W. E. (2002). Reducing
suicide: A national imperative. Washington D.C.: The National Academies Press.
58
Gunnell, D. and Eddleston, M. (2003). Suicide by intentional ingestion of pesticides: a con-
tinuing tragedy in developing countries. International Journal of Epidemiology,
32(6): 902-909.
Hamdi, E., Amin, Y. and Mattar, T. (1991). Clinical correlates of intent in attempted suicide.
Acta Psychiatrica Scandinavica, 83(5): 406-411.
Harriss, L. and Hawton, K. (2005). Suicidal intent in deliberate self-harm and the risk of
suicide: the predictive power of the Suicide Intent Scale. Journal of Affective Dis-
orders, 86(2-3): 225-233.
Harriss, L., Hawton, K. and Zahl, D. (2005). Value of measuring suicidal intent in the as-
sessment of people attending hospital following self-poisoning or self-injury. The
British Journal of Psychiatry, 186: 60-66.
Haw, C., Hawton, K., Houston, K. and Townsend, E. (2003). Correlates of relative lethality
and suicidal intent among deliberate self-harm patients. Suicide and Life-
Threatening Behavior, 33(4): 353-364.
Hawton, K. (2000). General hospital management of suicide attempters. The international
handbook of suicide and attempted suicide. K. Hawton and K. van Heeringen
(Eds.). New York: Wiley.
Hawton, K., Zahl, D. and Weatherall, R. (2003). Suicide following deliberate self-harm:
long-term follow-up of patients who presented to a general hospital. The British
Journal of Psychiatry, 182: 537-542.
Hay, D. (2002). The spirituality of adults in Britain – recent research. Scottish Journal of
Healthcare Chaplaincy, 5(1): 4-10.
Hegerl, U. and Althaus, D. (2003). [From patient screening to management list in suicide
risk. Practical guideline for dealing with depression]. MMW Fortschritte der
Medizin, 145(41): 24-27.
Helliwell, J. F. and Putnam, R. D. (2004). The social context of well-being. Philosophical
Transactions of the Royal Society of London. Series B, Biological Sciences,
359(1449): 1435-1446.
Henkel, V., Mergl, R., Coyne, J. C., Kohnen, R., Möller, H. J. and Hegerl, U. (2004a).
Screening for depression in primary care: will one or two items suffice? European
Archives of Psychiatry and Clinical Neuroscience, 254(4): 215-223.
Henkel, V., Mergl, R., Kohnen, R., Allgaier, A. K., Möller, H. J. and Hegerl, U. (2004b).
Use of brief depression screening tools in primary care: consideration of heteroge-
neity in performance in different patient groups. General Hospital Psychiatry,
26(3): 190-198.
Henkel, V., Mergl, R., Kohnen, R., Maier, W., Möller, H. J. and Hegerl, U. (2003). Identify-
ing depression in primary care: a comparison of different methods in a prospective
cohort study. BMJ, 326(7382): 200-201.
Heun, R., Burkart, M., Maier, W. and Bech, P. (1999). Internal and external validity of the
WHO Well-Being Scale in the elderly general population. Acta Psychiatrica Scan-
dinavica, 99(3): 171-178.
Hjelmeland, H. (1995). Verbally expressed intentions of parasuicide: I. characteristics of
patients with various intentions. Crisis, 16(4): 176-181.
Hjelmeland, H. (1996). Verbally expressed intentions of parasuicide: II. Prediction of fatal
and nonfatal repetition. Crisis, 17(1): 10-14.
Hjelmeland, H. and Hawton, K. (2004). Intentional Aspects of Non-Fatal Suicidal Behav-
iour. Suicidal Behaviour: Theories and Research Findings. D. De Leo, U. Bille-
Brahe, J. F. Kerkhof and A. Schmidtke (Eds.). Cambridge/Göttingen: Hogrefe &
Huber Publishers: 67-78.
59
Hjelmeland, H. and Knizek, B. L. (1999a). Conceptual confusion about intentions and mo-
tives of nonfatal suicidal behavior: A discussion of terms employed in the literature
of suicidology. Archives of Suicide Research, 5(4): 277-283.
Hjelmeland, H. and Knizek, B. L. (1999b). Conceptual confusion about intentions and mo-
tives of nonfatal suicidal behaviour: A discussion of terms employed in the litera-
ture of suicidology. Archives of Suicide Research, 5: 275-281.
Hjelmeland, H., Knizek, B. L. and Nordvik, H. (2002). The communicative aspect of nonfa-
tal suicidal behavior - are there gender differences? Crisis, 23(4): 144-155.
Hjelmeland, H., Nordvik, H., Bille-Brahe, U., De Leo, D., Kerkhof, J. F., Lonnqvist, J.,
Michel, K., Renberg, E. S., Schmidtke, A. and Wasserman, D. (2000). A cross-
cultural study of suicide intent in parasuicide patients. Suicide and Life-
Threatening Behavior, 30(4): 295-303.
Hulten, A., Wasserman, D., Hawton, K., Jiang, G. X., Salander-Renberg, E., Schmidtke, A.,
Bille-Brahe, U., Bjerke, T., Kerkhkof, A., Michel, K. and Querejeta, I. (2000).
Recommended care for young people (15-19 years) after suicide attempts in certain
European countries. European Child & Adolescent Psychiatry, 9(2): 100-108.
Huppert, F. A. and Baylis, N. (2004). Well-being: towards an integration of psychology,
neurobiology and social science. Philosophical Transactions of the Royal Society
of London. Series B, Biological Sciences, 359(1449): 1447-1451.
Huppert, F. A., Baylis, N. and Keverne, B. (2004). Introduction: why do we need a science
of well-being? Philosophical Transactions of the Royal Society of London. Series
B, Biological Sciences, 359(1449): 1331-1332.
ICD-10 (1990/2007). International Classification of Diseases, 10th Revision (ICD-10). Re-
trieved March 12, 2010 from
http://www.who.int/classifications/apps/icd/icd10online/.
Inglehart, R. (1997). Modernization and postmodernization: cultural, economic, and politi-
cal change in 43 societies. Princeton, N.J.: Princeton University Press.
Joiner, T. E., Jr., Brown, J. S. and Wingate, L. R. (2005). The psychology and neurobiology
of suicidal behavior. Annual Review of Psychology, 56: 287-314.
Kelleher, M. J., Chambers, D., Corcoran, P., Williamson, E. and Keeley, H. S. (1998). Reli-
gious sanctions and rates of suicide worldwide. Crisis, 19(2): 78-86.
Kerkhof, A. J. F. M., Bernasco, W., Bille-Brahe, U., Platt, S. and Schmidtke, A. (1999).
European Parasuicide Study Interview Schedule (EPSIS). Facts and Figures:
WHO/EURO. U. Bille-Brahe (Ed.). Copenhagen: WHO Regional Office for
Europe.
Kessing, L. V., Hansen, H. V. and Bech, P. (2006). General health and well-being in outpa-
tients with depressive and bipolar disorders. Nordic Journal of Psychiatry, 60(2):
150-156.
Khan, M. M. and Reza, H. (2000). The pattern of suicide in Pakistan. Crisis, 21(1): 31-35.
Koenig, H. G. (2005). Faith And Mental Health: Religious Resources for Healing. West
Conshohocken: Templeton Foundation Press.
Koenig, H. G., McCullough, M. E. and Larson, D. B. (2001). Handbook of Religion and
Health. New York: Oxford University Press.
Kreitman, N. (1977). Parasuicide. London: John Wiley.
Kreitman, N., Philip, A. E., Greer, S. and Bagley, C. R. (1969). Parasuicide. The British
Journal of Psychiatry, 115(523): 746-747.
Kuo, W. H., Gallo, J. J. and Eaton, W. W. (2004). Hopelessness, depression, substance dis-
order, and suicidality--a 13-year community-based study. Social Psychiatry and
Psychiatric Epidemiology, 39(6): 497-501.
60
Kõlves, K., Värnik, A., Tooding, L. M. and Wasserman, D. (2006). The role of alcohol in
suicide: a case-control psychological autopsy study. Psychological Medicine,
36(7): 923-930.
Lagerspetz, M. (1996). Constructing post-communism: a study in the Estonian social prob-
lems discourse. Turku: Turun Yliopisto.
Latha, K. S., Bhat, S. M. and D'Souza, P. (1996). Suicide attempters in a general hospital
unit in India: their socio-demographic and clinical profile-emphasis on cross-
cultural aspects. Acta Psychiatrica Scandinavica, 94(1): 26-30.
Lester, D. (2001). Nonfatal suicidal behavior as a communication. Crisis, 22(2): 49-51.
Lester, D. (2006). Suicide and Islam. Archives of Suicide Research, 10(1): 77-97.
Löhr, C. and Schmidtke, A. (2004). Marital relations of suicide attempters. Suicidal Behav-
iour: Theories and Research Findings. D. De Leo, U. Bille-Brahe, A. Kerkhof and
A. Schmidtke (Eds.). Cambridge/Göttingen: Hogrefe & Huber: 125-137.
Löwe, B., Spitzer, R. L., Gräfe, K., Kroenke, K., Quenter, A., Zipfel, S., Buchholz, C.,
Witte, S. and Herzog, W. (2004). Comparative validity of three screening ques-
tionnaires for DSM-IV depressive disorders and physicians' diagnoses. Journal of
Affective Disorders, 78(2): 131-140.
Lyons, C., Price, P., Embling, S. and Smith, C. (2000). Suicide risk assessment: a review of
procedures. Accident and Emergency Nursing, 8(3): 178-186.
MacLeod, A. K., Tata, P., Tyrer, P., Schmidt, U., Davidson, K. and Thompson, S. (2005).
Hopelessness and positive and negative future thinking in parasuicide. The British
Journal of Clinical Psychology, 44(Pt 4): 495-504.
Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., Hegerl, U.,
Lonnqvist, J., Malone, K., Marusic, A., Mehlum, L., Patton, G., Phillips, M., Rutz,
W., Rihmer, Z., Schmidtke, A., Shaffer, D., Silverman, M., Takahashi, Y., Varnik,
A., Wasserman, D., Yip, P. and Hendin, H. (2005). Suicide prevention strategies: a
systematic review. JAMA, 294(16): 2064-2074.
Maris, R. W. (1981). Pathways to suicide: A survey of self-destructive behaviors. Baltimore,
MD: John Hopkins University Press.
Maris, R. W., Berman, A. L., Silverman, M. M. and Bongar, B. M. (2000). Comprehensive
textbook of suicidology. New York: Guilford Press.
McAuliffe, C., Arensman, E., Keeley, H. S., Corcoran, P. and Fitzgerald, A. P. (2007). Mo-
tives and suicide intent underlying hospital treated deliberate self-harm and their
association with repetition. Suicide and Life-Threatening Behavior, 37(4): 397-408.
Michel, K., Valach, L. and Waeber, V. (1994). Understanding deliberate self-harm: the
patients' views. Crisis, 15(4): 172-178.
Mitchell, A. J. and Dennis, M. (2006). Self harm and attempted suicide in adults: 10 practi-
cal questions and answers for emergency department staff. Emergency Medicine
Journal, 23(4): 251-255.
Mittendorfer Rutz, E. and Schmidtke, A. (2009). Suicide attempts in Europe. Oxford Text-
book of Suicidology and Suicide Prevention: A Global Perspective. D. Wasserman
and C. Wasserman (Eds.). Oxford, UK: Oxford University Press: 123-126.
Moreira-Almeida, A., Neto, F. L. and Koenig, H. G. (2006). Religiousness and mental
health: a review. Revista Brasileira de Psiquiatria, 28(3): 242-250.
Musick, M. A., House, J. S. and Williams, D. R. (2004). Attendance at religious services and
mortality in a national sample. Journal of Health and Social Behavior, 45(2): 198-
213.
61
Mäkinen, I. H. (1997). On Suicide in European Countries. Some Theoretical, Legal and
Historical Views on Suicide Mortality and Its Concomitants. Stockholm: Stock-
holm University.
Mäkinen, I. H. (2009). Social theories of suicide. Oxford Textbook of Suicidology and Sui-
cide Prevention: A Global Perspective. D. Wasserman and C. Wasserman (Eds.).
Oxford, UK: Oxford University Press: 139-147.
Möller, H. J. (2003). Suicide, suicidality and suicide prevention in affective disorders. Acta
Psychiatrica Scandinavica. Supplementum, 418: 73-80.
National Strategy for Suicide Prevention (2001). Goals and Objective for Action. Rockville,
MD: US Department of Health and Human Services, Public Health Service.
Neeleman, J. (1998). Regional suicide rates in the Netherlands: does religion still play a
role? International Journal of Epidemiology, 27(3): 466-472.
Neeleman, J., de Graaf, R. and Vollebergh, W. (2004). The suicidal process; prospective
comparison between early and later stages. Journal of Affective Disorders, 82(1):
43-52.
Nielsen, A. S., Stenager, E. and Brahe, U. B. (1993). Attempted suicide, suicidal intent, and
alcohol. Crisis, 14(1): 32-38.
Niméus, A., Alsén, M. and Träskman-Bendz, L. (2002). High suicidal intent scores indicate
future suicide. Archives of Suicide Research, 6(3): 211-219.
Nisbet, P. A., Duberstein, P. R., Conwell, Y. and Seidlitz, L. (2000). The effect of participa-
tion in religious activities on suicide versus natural death in adults 50 and older.
The Journal of Nervous and Mental Disease, 188(8): 543-546.
Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., Bruf-
faerts, R., Chiu, W. T., de Girolamo, G., Gluzman, S., de Graaf, R., Gureje, O.,
Haro, J. M., Huang, Y., Karam, E., Kessler, R. C., Lepine, J. P., Levinson, D., Me-
dina-Mora, M. E., Ono, Y., Posada-Villa, J. and Williams, D. (2008). Cross-
national prevalence and risk factors for suicidal ideation, plans and attempts. The
British Journal of Psychiatry, 192(2): 98-105.
O'Caroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L. and Silverman,
M. M. (1996). Beyond the Tower of Babel: a nomenclature for suicidology. Suicide
and Life-Threatening Behavior, 26(3): 237-252.
Parsons, T. (1937/1968). The structure of social action: a study in social theory with special
reference to a group of recent European writers. New York: Free Press.
Pescosolido, B. A. and Georgianna, S. (1989). Durkheim, suicide, and religion: toward a
network theory of suicide. American Sociological Review, 54(1): 33-48.
Phillips, M. R., Li, X. and Zhang, Y. (2002a). Suicide rates in China, 1995-99. Lancet,
359(9309): 835-840.
Phillips, M. R., Yang, G., Zhang, Y., Wang, L., Ji, H. and Zhou, M. (2002b). Risk factors for
suicide in China: a national case-control psychological autopsy study. Lancet,
360(9347): 1728-1736.
Pierce, D. W. (1977). Suicidal intent in self-injury. The British Journal of Psychiatry, 130:
377-385.
Platt, S., Bille-Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T., Crepet, P., De Leo, D.,
Haring, C., Lonnqvist, J., Michel, K. and et al. (1992). Parasuicide in Europe: the
WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary
analysis for 1989. Acta Psychiatrica Scandinavica, 85(2): 97-104.
Primack, B. A. (2003). The WHO-5 Wellbeing Index performed the best in screening for
depression in primary care. ACP Journal Club, 139(2): 48.
62
Roberts, D. M., Karunarathna, A., Buckley, N. A., Manuweera, G., Sheriff, M. H. and Ed-
dleston, M. (2003). Influence of pesticide regulation on acute poisoning deaths in
Sri Lanka. Bulletin of the World Health Organization, 81(11): 789-798.
Runeson, B. S., Beskow, J. and Waern, M. (1996). The suicidal process in suicides among
young people. Acta Psychiatrica Scandinavica, 93(1): 35-42.
Ryan, R. M. and Deci, E. L. (2001). On happiness and human potentials: a review of re-
search on hedonic and eudaimonic well-being. Annual Review of Psychology, 52:
141-166.
Ryan, R. M., Huta, V. and Deci, E. L. (2008). Living well: A self-determination theory
perspective on eudaimonia. Journal of Happiness Studies, 9(1): 139-170.
Schmidtke, A., Bille-Brahe, U., DeLeo, D., Kerkhof, A., Bjerke, T., Crepet, P., Haring, C.,
Hawton, K., Lonnqvist, J., Michel, K., Pommereau, X., Querejeta, I., Phillipe, I.,
Salander-Renberg, E., Temesvary, B., Wasserman, D., Fricke, S., Weinacker, B.
and Sampaio-Faria, J. G. (1996). Attempted suicide in Europe: rates, trends and so-
ciodemographic characteristics of suicide attempters during the period 1989-1992.
Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica
Scandinavica, 93(5): 327-338.
Schmidtke, A., Weinacker, B., Löhr, C., Bille-Brahe, U., De Leo, D., Kerkhof, A., Apter, A.,
Batt, A., Crepet, P., Fekete, S., Grad, O., Haring, C., Hawton, K., van Heeringen,
C., Hjelmeland, H., Kelleher, M., Lönnquist, J., Michel, K., Pommerau, X., Quere-
jeta, I., Philippe, A., Salander Renberg, E., Sayil, I., Temesvary, B., Värnik, A.,
Wasserman, D. and Rutz, W. (2004). Suicide and Suicide Attempts in Europe. Sui-
cidal Behaviour in Europe: Results from the WHO/Euro Multicentre Study on Sui-
cidal Behaviour. A. Schmidtke, U. Bille-Brahe, D. De Leo and A. Kerkhof (Eds.).
Cambridge/Göttingen: Hogrefe & Huber: 15-28.
Searle, J. R. (1995). The construction of social reality. London: Penguin Books.
Siegrist, M. (1996). Church attendance, denomination, and suicide ideology. The Journal of
Social Psychology, 136(5): 559-566.
Silverman, M. M. (2006a). In this Issue. Suicide and Life-Threatening Behavior, 36(6): iii.
Silverman, M. M. (2006b). The Language of Suicidology. Suicide and Life-Threatening
Behavior, 36(5): 519-532.
Silverman, M. M., Berman, A. L., Sanddal, N. D., O'Carroll P, W. and Joiner, T. E. (2007a).
Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and
suicidal behaviors. Part 1: Background, rationale, and methodology. Suicide and
Life-Threatening Behavior, 37(3): 248-263.
Silverman, M. M., Berman, A. L., Sanddal, N. D., O'Carroll P, W. and Joiner, T. E. (2007b).
Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and
suicidal behaviors. Part 2: Suicide-related ideations, communications, and behav-
iors. Suicide and Life-Threatening Behavior, 37(3): 264-277.
Simpson, M. E. and Conklin, G. H. (1988). Socioeconomic Development, Suicide and Relig-
ion: A Test of Durkheim's Theory of Religion and Suicide. Social Forces, 67(4):
945-964.
Skegg, K. (2005). Self-harm. Lancet, 366(9495): 1471-1483.
Spector, M. and Kitsuse, J. I. (1987). Constructing social problems. New York: Aldine de
Gruyter.
Spicer, R. S. and Miller, T. R. (2000). Suicide acts in 8 states: incidence and case fatality
rates by demographics and method. American Journal of Public Health, 90(12):
1885-1891.
63
Stack, S. (1983). The effect of religious commitment on suicide: a cross-national analysis.
Journal of Health and Social Behavior, 24(4): 362-374.
Stack, S. (2000). Suicide: a 15-year review of the sociological literature. Part II: moderniza-
tion and social integration perspectives. Suicide and Life-Threatening Behavior,
30(2): 163-176.
Stack, S. and Kposowa, A. J. (2008). The Association of Suicide Rates with Individual-
Level Suicide Attitudes: A Cross-National Analysis. Social Science Quarterly,
89(1): 39-59.
Stack, S. and Lester, D. (1991). The effect of religion on suicide ideation. Social Psychiatry
and Psychiatric Epidemiology, 26(4): 168-170.
Stengel, E. (1962). Recent research into suicide and attempted suicide. The American Jour-
nal of Psychiatry, 118: 725-727.
Stengel, E. (1964). Suicide and attempted suicide. Baltimore: Penguin.
Suominen, K., Isometsa, E., Ostamo, A. and Lonnqvist, J. (2004). Level of suicidal intent
predicts overall mortality and suicide after attempted suicide: a 12-year follow-up
study. BMC Psychiatry, 4: 11.
Thanh, H. T., Jiang, G. X., Van, T. N., Minh, D. P., Rosling, H. and Wasserman, D. (2005).
Attempted suicide in Hanoi, Vietnam. Social Psychiatry and Psychiatric Epidemi-
ology, 40(1): 64-71.
Tooding, L. M., Värnik, A. and Wasserman, D. (2004). Gender and age-specific dynamics of
suicides in the Baltic states during the transition period. Trames, 8: 299-308.
Tousignant, M., Seshadri, S. and Raj, A. (1998). Gender and suicide in India: a multiper-
spective approach. Suicide and Life-Threatening Behavior, 28(1): 50-61.
Townsend, E. (2007). Suicide Terrorists: Are They Suicidal? Suicide and Life-Threatening
Behavior, 37(1): 35-49.
Wassenaar, D. R., van der Veen, M. B. W. and Pillay, A. L. (1998). Women in cultural
transition: suicidal behavior in South African Indian women. Suicide and Life-
Threatening Behavior, 28(1): 82-93.
Wasserman, D. (2001a). Affective disorders and suicide. Suicide: An unnecessary death. D.
Wasserman (Ed.). London: Martin Dunitz: 39-47.
Wasserman, D. (2001b). A stress-vulnerability model and the development of the suicidal
process. Suicide: An unnecessary death. D. Wasserman (Ed.). London: Martin
Dunitz: 13-27.
Wasserman, D., Dankowicz, M., Värnik, A. and Olsson, L. (1997). Suicide trends in Europe,
1984-1990. Suicide: Biopsychosocial Approaches. A. J. Botsis, C. R. Soldatos and
C. N. Stefanis (Eds.). Amsterdam: Elsevier: 3-10.
Wasserman, D. and Wasserman, C. (2009). Oxford Textbook of Suicidology and Suicide
Prevention: A Global Perspective. Oxford, UK: Oxford University Press.
Wasserman, D. and Värnik, A. (1994). Increase in suicide among men in the Baltic coun-
tries. Lancet, 343(8911): 1504-1505.
Wasserman, D. and Värnik, A. (2001). Perestroika in the former USSR: history's most effec-
tive suicide preventive programme for men. Suicide: An unnecessary death. D.
Wasserman (Ed.). London: Martin Dunitz: 253-258.
Wasserman, D., Värnik, A. and Dankowicz, M. (1998). Regional differences in the distribu-
tion of suicide in the former Soviet Union during perestroika, 1984-1990. Acta
Psychiatrica Scandinavica. Supplementum, 394: 5-12.
Watson, D., Goldney, R., Fisher, L. and Merritt, M. (2001). The measurement of suicidal
ideation. Crisis, 22(1): 12-14.
64
Weber, M., Roth, G. and Wittich, C. (1921/1978). Economy and society: an outline of inter-
pretive sociology. Berkeley: University of California Press.
WHO (1998). Info Package: Mastering Depression in Primary Care. Fredriksborg: World
Health Organization, Regional Office for Europe, Psychiatric Research Unit.
WHO (2002). Multisite Intervention Study on Suicidal Behaviours SUPRE-MISS: Protocol
of SUPRE-MISS. Geneva: World Health Organization.
WHO/Euro MDB (2010). European Mortality Database (MDB), WHO Regional Office for
Europe. Retrieved January, 2010 from http://data.euro.who.int/hfamdb/.
Vijayakumar, L. (2003). Psychosocial risk factors for suicide in India. Suicide Prevention:
Meeting the Challenge Together. L. Vijayakumar (Ed.). India: Orient Longman:
149-162.
Vijayakumar, L., John, S., Pirkis, J. and Whiteford, H. (2005). Suicide in developing coun-
tries (2): risk factors. Crisis, 26(3): 112-119.
Williams, J. M. G. and Pollock, L. R. (2000). The psychology of suicidal behaviour. Chices-
ter, UK: Willey.
Värnik, A. (1998). Suicide in the former republics of the USSR. Psychiatria Fennica, 29:
150-162.
Värnik, A. (2005). Suitsiid on rahva vaimujõu peegel [Suicide as a mirror of society's mental
health]. Eesti edu hind. Eesti sotsiaalne julgeolek ja rahva turvalisus. E. Raska and
T. Raitviir (Eds.). Tallinn: Eesti Entsüklopeediakirjastus: 130-136.
Värnik, A. and Mokhovikov, A. (2009). Suicide during transition in the former Soviet Re-
publics. Oxford Textbook of Suicidology and Suicide Prevention. D. Wasserman
and C. Wasserman (Eds.). Oxford, UK: Oxford University Press: 191-199.
Värnik, A., Tooding, L. M., Palo, E. and Wasserman, D. (2000). Suicide Trends in the Baltic
States, 1970-1997. Trames, 4: 79-90.
Värnik, A., Tooding, L. M., Palo, E. and Wasserman, D. (2003). Suicide and Homicide:
Durkheim's and Henry & Short Theories Tested on Data from the Baltic States. Ar-
chives of Suicide Research, 7: 51-59.
Värnik, A. and Wasserman, D. (2009). Suicide Prevention in Estonia. Oxford Textbook of
Suicidology and Suicide Prevention. D. Wasserman and C. Wasserman (Eds.). Ox-
ford, UK: Oxford University Press: 791-792.
Värnik, A., Wasserman, D., Dankowicz, M. and Eklund, G. (1998). Marked decrease in
suicide among men and women in the former USSR during perestroika. Acta Psy-
chiatrica Scandinavica. Supplementum, 394: 13-19.
Värnik, P., Sisask, M., Värnik, A., Yur'yev, A., Kõlves, K., Leppik, L., Nemtsov, A. and
Wasserman, D. (2010). Massive increase in injury deaths of undetermined intent in
ex-USSR Baltic and Slavic countries: Hidden suicides? Scandinavian Journal of
Public Health, 38(4): 395-403.
Yip, P. S. and Cheung, Y. B. (2006). Quick assessment of hopelessness: a cross-sectional
study. Health and Quality of Life Outcomes, 4: 13.

65
49





PUBLICATIONS























PUBLICA1IONS
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 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 in
emergency-care settings of general hospitals in eight
low- and middle-income countries
ALEXANDRA FLEI SCHMANN
1
, J OSE
´
M. BERTOLOTE
1
*, DI EGO DE LEO
2
,
NEURY BOTEGA
3
, MI CHAEL PHI LLI PS
4
, MERI KE SI SASK
5
,
LAKSHMI VI J AYAKUMAR
6
, KAZEM MALAKOUTI
7
, LOURENS SCHLEBUSCH
8
,
DAMANI DE SI LVA
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 Mental
Health 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 Health
Sciences, 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 Institute
and Swedish National Institute of Psychosocial Medicine, Stockholm, Sweden
ABSTRACT
Background. The objective was to describe patients presenting themselves at emergency-care
settings 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 emergency
units of 18 collaborating hospitals were asked to participate in a 45-minute structured interview
administered 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-poisoning
by pesticides played a particularly important role in Yuncheng (71
.
6% females, 61
.
5% males), in
Colombo (43
.
2% males, 19
.
6% females), and in Chennai (33
.
8% males, 23
.
8% females). The
suicide 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 for
follow-up evaluation or care.
Conclusions. Action for the prevention of suicide attempts can be started immediately in the
sites 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 substances
need to be improved and revised regulations must be implemented by integrating the efforts
of different sectors, such as health, agriculture, education, and justice. The care of patients who
attempt suicide needs to include routine psychiatric and psychosocial assessment and systematic
referral 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 : bertolotej@who.int)
Psychological Medicine, 2005, 35, 1467–1474. f 2005 Cambridge University Press
doi:10.1017/S0033291705005416 Printed in the United Kingdom
1467
70
INTRODUCTION
Suicide is not only a global and personal
tragedy, but also a major public health problem.
In 2002, it was estimated that 877 000 lives were
lost due to suicide (WHO, 2003). Suicide occurs
in both developed and developing countries, in
all age groups. For the past few decades the
global picture has been one of rising trends,
particularly among younger age groups, where
suicide is among the five leading causes of death
for both sexes.
Depending on the location, suicide attempts
can be up to 10–40 times more frequent than
completed suicides (Schmidtke et al. 1996). In
many countries, suicide attempts are one of the
main reasons for hospital emergency treatment
of young people, putting a heavy burden on
health-care systems. The majority of individuals
who attempt suicide tend to be adolescents
and young adults, and together they form a
pool from which many future suicides emerge
(United Nations Department for Policy Co-
ordination and Sustainable Development, 1996;
Hulte´ n et al. 2000).
Whereas many WHO Member States report
on mortality, including suicide mortality, no
official or systematically collected statistics on
suicide attempts exist on a national basis. The
WHO/EURO multicentre study on suicidal be-
haviour, monitored attempted suicides treated
at 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 cannot
be construed as representing the respective
‘ national reality’.
In 2000, the WHO launched the multisite
intervention study on suicidal behaviours
(SUPRE-MISS) which aimed to increase knowl-
edge about suicidal behaviours and about the
effectiveness of interventions for suicide at-
tempters in culturally diverse places around the
world.
SUPRE-MISS has three components: (i)
a randomized clinical trial to evaluate treat-
ment strategies for suicide attempters re-
suscitated in emergency settings in defined
catchment areas; (ii) a community survey to
identify suicidal ideation and behaviour in
the 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 of
the suicide attempters of the intake component
(i). The majority of these participated in the
randomized clinical controlled trial.
METHOD
The emergency-care departments
The study was carried out in one or more
emergency-care departments of the partici-
pating sites. In Campinas (Brazil), it was
Hospital das Clinicas, Universidade Estadual de
Campinas. In Chennai (India), the Government
Royapettah Hospital. In Colombo (Sri Lanka),
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
involved in the study. In Hanoi (Viet Nam), 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 Mustamae Hospital and
the Tallinn Psychiatric Clinic) participated. In
Yuncheng (People’s Republic of China), it was
the Yuncheng County Hospital. These hospitals
served the respective catchment area of the
participating sites which were mostly urban,
except for Yuncheng which was rural.
Subjects
All suicide attempters identified between
January 2002 and January 2004 (in Hanoi up
to April 2004) in emergency-care settings by
medical staff within a catchment area with a
population of at least 250 000 in eight countries
were invited to participate in the study. Those
who agreed, filled in a consent form and were
administered the detailed intake interview.
A total of 4314 subjects were included. Their
distribution by age, sex and site is given in
Table 1.
Interviewing
At each site 2–12 psychiatrists, medical doctors,
psychologists and, in one instance, psychiatric
nurses 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-care
departments. Suicide attempters were identified
by the medical staff in the emergency rooms
and interviewed once medically stable, at most
3 days after the emergency room admission.
Instrument
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
covered a detailed intake part comprising
the method of the suicide attempt, physical
consequences, the type of care and referral as
determined by the medical staff, as well as socio-
demographic information. A series of other
variables was also answered, the results of which
are not reported here (WHO, 2002a).
RESULTS
The intake of subjects
An attempt was made to include all suicide
attempters seen at the emergency-care de-
partments. However, inadequate 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) made it difficult
to include all eligible patients in the intake, to
enrol them eventually and, in some instances,
even to make an accurate assessment of the
total number of suicide attempters coming to
the emergency-care units. Given the nature of
these reasons, it is impossible to both estimate
the number of these ‘ losses’ and identify means
of avoiding them.
In Karaj (n=945) and Hanoi (n=301) all
suicide attempters identified in the emergency-
care departments over the specified period
participated in the intake evaluation. In Cam-
pinas (n=162), Durban (n=570) and Colombo
(n=1067) almost all subjects completed the
intake interview. However, the total number of
suicide attempters seen at the emergency-care
department was not known, because it was
suspected that a small (unknown) number of
cases was not notified by the emergency
departments to the researchers: the subjects
could have been admitted directly to a psy-
chiatric unit without being treated in the
emergency department or the subjects might
have left before the research team could meet
them. Also, in Colombo almost all self-
poisoning and surgically serious self-injury
patients who were admitted participated in the
intake evaluation, but the number of suicide
attempts that were not seen at the acute care
wards was unknown.
In Chennai 680 out of 1691 (40%), in Tallinn
469 out of 884 (53%) and in Yuncheng 120
out of 194 (62%) suicide attempters seen in the
emergency-care departments participated in
the intake interview. Of those who did not
participate, only sex and age are known; the
majority of those not interviewed precipitously
left the emergency-care department before the
researchers arrived to conduct the interview.
Sociodemographic characteristics
In all sites, more female than male suicide
attempters 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) indicated
themselves to be transsexual. Overall, the
patients were young. The median age among
females 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 68
Age (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 where
the median age of females was higher than for
males (Table 1).
In six of the eight countries male attempters
were more likely to be single than married, and
in four of the eight countries female attempters
were more likely to be single than married. In all
sites, except for Campinas, female attempters
were more likely to be married than male
attempters (Table 2). Divorce was common
among suicide attempters in Campinas (17
.
5%
males, 22
.
3% females) and in Tallinn (13
.
0%
males, 14
.
6% females). In all sites, except for
Campinas, women were more frequently
married than men (Table 2).
With the exception of Yuncheng (where
men had a higher educational attainment than
women) the educational achievement of male
and female suicide attempters was similar
(Table 2).
Except for Durban and Karaj the majority
of subjects were employed full-time or part-time
at the time of admission to the emergency-care
departments. The other common employment
categories were ‘ unemployed’, ‘ housekeeper’
and ‘ full-time student’ (Table 2).
Main method of the suicide attempt according
to ICD-10 codes
Self-poisoning – which accounted for 69–98%
of all cases – was the predominant method of
suicide attempts seen in the emergency depart-
ments at all sites, far exceeding the other
methods of ‘ cutting’, ‘ hanging’, etc. (Table 3).
In most cases self-poisoning involved the
ingestion of pesticides or medications. In
Yuncheng pesticide ingestion was the most
frequently reported method among both men
(61
.
5%) and women (71
.
6%) ; in Colombo and
Chennai it was the most commonly used
method in men (43
.
2% and 33
.
8% respectively)
and the second most commonly used method in
women (19
.
6% and 23
.
8% respectively) ; it was
also an important method in Campinas and
Hanoi.
More than one method, i.e. a combination of
methods, was rarely applied. The one exception
was in Tallinn, where 10
.
7% of the suicide
attempters combined self-poisoning by alcohol
with another method. T
a
b
l
e
2
.
S
o
c
i
o
-
d
e
m
o
g
r
a
p
h
i
c
c
h
a
r
a
c
t
e
r
i
s
t
i
c
s
o
f
s
u
i
c
i
d
e
a
t
t
e
m
p
t
e
r
s
s
e
e
n
a
t
e
m
e
r
g
e
n
c
y
-
c
a
r
e
h
o
s
p
i
t
a
l
s
i
n
S
U
P
R
E
-
M
I
S
S
s
i
t
e
s
(
%
r
o
u
n
d
e
d
)
C
a
m
p
i
n
a
s
C
h
e
n
n
a
i
C
o
l
o
m
b
o
D
u
r
b
a
n
H
a
n
o
i
K
a
r
a
j
T
a
l
l
i
n
n
Y
u
n
c
h
e
n
g
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
a
r
i
t
a
l
s
t
a
t
u
s
(
n
=
5
7
)
(
n
=
1
0
3
)
(
n
=
3
3
1
)
(
n
=
3
4
9
)
(
n
=
4
6
5
)
(
n
=
5
8
9
)
(
n
=
1
5
5
)
(
n
=
4
0
0
)
(
n
=
8
7
)
(
n
=
2
1
1
)
(
n
=
3
9
5
)
(
n
=
5
4
8
)
(
n
=
1
6
1
)
(
n
=
3
0
8
)
(
n
=
3
9
)
(
n
=
8
1
)
S
i
n
g
l
e
2
8
3
5
5
0
4
0
5
9
5
7
6
8
6
8
7
0
5
9
6
7
4
1
4
7
3
3
2
3
1
6
M
a
r
r
i
e
d
5
1
4
1
4
7
5
4
3
8
4
2
1
9
2
4
2
8
3
9
3
1
5
6
3
9
4
6
6
9
8
2
S
e
p
a
r
a
t
e
d
a
2
1
2
4
3
6
2
2
1
3
8
2
2
2
3
1
4
2
1
8
2
E
d
u
c
a
t
i
o
n
(
n
=
5
7
)
(
n
=
1
0
4
)
(
n
=
3
3
0
)
(
n
=
3
4
9
)
(
n
=
4
3
8
)
(
n
=
5
6
9
)
(
n
=
1
5
2
)
(
n
=
4
0
1
)
(
n
=
5
3
)
(
n
=
1
6
7
)
(
n
=
3
9
6
)
(
n
=
5
4
9
)
(
n
=
1
6
1
)
(
n
=
3
0
8
)
(
n
=
3
9
)
(
n
=
8
1
)
N
o
n
e
1
1
1
4
9
1
9
4
4
3
2
0
1
2
4
4
5
1
5
2
8
P
r
i
m
a
r
y
4
7
3
9
2
8
2
4
1
5
9
3
8
2
9
4
1
1
3
1
0
2
4
2
4
3
1
4
7
S
e
c
o
n
d
a
r
y
2
5
2
0
4
8
4
3
7
9
8
3
5
1
6
1
2
1
1
5
3
3
2
3
3
2
3
3
4
9
2
4
H
i
g
h
e
r
1
4
2
6
1
6
1
4
1
4
7
7
6
4
6
1
5
3
6
3
3
8
3
6
5
1
O
t
h
e
r
4
1
0
0
0
0
1
2
1
1
2
2
0
0
2
2
0
0
E
m
p
l
o
y
m
e
n
t
(
n
=
5
2
)
(
n
=
9
0
)
(
n
=
3
2
3
)
(
n
=
3
0
8
)
(
n
=
4
4
6
)
(
n
=
5
5
1
)
(
n
=
1
4
2
)
(
n
=
3
7
0
)
(
n
=
6
4
)
(
n
=
1
7
0
)
(
n
=
3
9
3
)
(
n
=
5
4
8
)
(
n
=
1
6
1
)
(
n
=
3
0
8
)
(
n
=
3
9
)
(
n
=
8
1
)
F
u
l
l
/
p
a
r
t
-
t
i
m
e
5
8
3
3
7
9
5
0
6
7
3
8
4
0
2
5
3
8
3
2
2
3
4
5
4
5
1
8
5
8
3
U
n
e
m
p
l
o
y
e
d
2
5
2
3
1
0
4
1
2
1
1
2
9
2
9
1
4
9
2
6
1
1
8
1
2
3
1
S
t
u
d
e
n
t
0
8
6
7
9
1
8
1
8
3
4
2
7
2
9
1
3
2
0
8
1
7
8
3
H
o
u
s
e
k
e
e
p
e
r
0
1
2
0
3
5
0
2
6
1
7
2
8
2
6
8
0
4
0
4
O
t
h
e
r
b
1
0
1
6
2
0
1
2
3
8
4
8
7
3
4
7
1
9
1
4
3
7
M
,
M
a
l
e
;
F
,
f
e
m
a
l
e
.
a
S
e
p
a
r
a
t
e
d
/
d
i
v
o
r
c
e
d
o
r
w
i
d
o
w
e
d
.
b
O
t
h
e
r
i
n
c
l
u
d
e
s
s
i
c
k
l
e
a
v
e
/
d
i
s
a
b
l
e
d
,
t
e
m
p
o
r
a
r
y
w
o
r
k
,
a
r
m
e
d
f
o
r
c
e
,
r
e
t
i
r
e
d
.
1470 A. Fleischmann et al.
73
T
a
b
l
e
3
.
M
a
i
n
m
e
t
h
o
d
o
f
a
t
t
e
m
p
t
e
d
s
u
i
c
i
d
e
a
c
c
o
r
d
i
n
g
t
o
I
C
D
-
1
0
c
o
d
e
s
i
n
S
U
P
R
E
-
M
I
S
S
s
i
t
e
s
(
%
r
o
u
n
d
e
d
)
C
a
m
p
i
n
a
s
C
h
e
n
n
a
i
C
o
l
o
m
b
o
D
u
r
b
a
n
H
a
n
o
i
K
a
r
a
j
T
a
l
l
i
n
n
Y
u
n
c
h
e
n
g
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
(
n
=
5
6
)
(
n
=
1
0
4
)
(
n
=
3
3
1
)
(
n
=
3
4
9
)
(
n
=
4
6
5
)
(
n
=
5
8
6
)
(
n
=
1
5
3
)
(
n
=
3
9
5
)
(
n
=
8
3
)
(
n
=
2
0
5
)
(
n
=
3
9
5
)
(
n
=
5
4
6
)
(
n
=
1
6
1
)
(
n
=
3
0
8
)
(
n
=
3
9
)
(
n
=
8
1
)
S
e
l
f
-
p
o
i
s
o
n
i
n
g
N
o
n
-
o
p
i
o
i
d
a
n
a
l
g
e
s
i
c
s
a
n
d
a
n
t
i
p
y
r
e
t
i
c
s
0
2
1
5
1
4
2
7
4
8
5
4
5
2
7
5
9
1
3
1
1
2
2
0
0
A
n
t
i
-
e
p
i
l
e
p
t
i
c
a
n
d
s
e
d
a
t
i
v
e
-
h
y
p
n
o
t
i
c
d
r
u
g
s
3
9
5
8
8
1
2
8
1
1
1
0
6
4
1
0
5
1
4
7
5
0
5
9
3
1
2
1
O
t
h
e
r
m
e
d
i
c
a
m
e
n
t
s
2
6
3
3
4
0
8
1
6
9
1
7
2
2
1
1
1
3
3
2
0
3
A
l
c
o
h
o
l
0
2
0
0
1
0
0
0
0
0
1
1
2
1
0
0
P
e
s
t
i
c
i
d
e
s
1
8
7
3
4
2
4
4
3
2
0
2
3
1
6
5
3
2
1
0
6
2
7
2
O
t
h
e
r
a
1
3
5
2
1
1
7
1
7
1
9
1
7
1
6
1
6
5
1
6
2
1
4
3
5
2
A
l
l
P
o
i
s
o
n
i
n
g
s
7
2
7
9
9
7
9
8
9
1
9
3
8
6
9
6
8
9
9
8
9
1
9
6
6
9
8
8
9
7
9
8
H
a
n
g
i
n
g
a
n
d
s
u

o
c
a
t
i
o
n
2
6
3
1
2
1
5
2
7
2
1
0
7
5
3
3
C
u
t
t
i
n
g
w
i
t
h
s
h
a
r
p
o
r
b
l
u
n
t
o
b
j
e
c
t
1
8
4
0
0
2
1
4
2
2
0
6
2
2
0
6
0
0
O
t
h
e
r
b
9
1
2
0
1
6
6
6
1
1
1
3
2
4
2
0
0
M
,
M
a
l
e
;
F
,
f
e
m
a
l
e
.
a
S
e
l
f
-
p
o
i
s
o
n
i
n
g
o
t
h
e
r
,
i
n
c
l
u
d
i
n
g
:
n
a
r
c
o
t
i
c
s
a
n
d
p
s
y
c
h
o
d
y
s
l
e
p
t
i
c
s
,
n
o
t
e
l
s
e
w
h
e
r
e
c
l
a
s
s
i

e
d
;
o
t
h
e
r
d
r
u
g
s
a
c
t
i
n
g
o
n
t
h
e
a
u
t
o
n
o
m
i
c
n
e
r
v
o
u
s
s
y
s
t
e
m
;
o
r
g
a
n
i
c
s
o
l
v
e
n
t
s
a
n
d
h
a
l
o
g
e
n
a
t
e
d
h
y
d
r
o
-
c
a
r
b
o
n
s
a
n
d
t
h
e
i
r
v
a
p
o
u
r
s
;
o
t
h
e
r
g
a
s
e
s
a
n
d
v
a
p
o
u
r
s
;
o
t
h
e
r
a
n
d
u
n
s
p
e
c
i

e
d
c
h
e
m
i
c
a
l
s
a
n
d
n
o
x
i
o
u
s
s
u
b
s
t
a
n
c
e
s
.
b
O
t
h
e
r
,
i
n
c
l
u
d
i
n
g
d
r
o
w
n
i
n
g
;
a
l
l

r
e
a
r
m
s
;
s
m
o
k
e
,

r
e
,
s
t
e
a
m
a
n
d
h
o
t
o
b
j
e
c
t
s
;
j
u
m
p
i
n
g
f
r
o
m
a
h
i
g
h
p
l
a
c
e
;
j
u
m
p
i
n
g
o
r
l
y
i
n
g
b
e
f
o
r
e
a
m
o
v
i
n
g
o
b
j
e
c
t
;
o
t
h
e
r
s
p
e
c
i

e
d
m
e
a
n
s
;
u
n
s
p
e
c
i

e
d
m
e
a
n
s
.
T
a
b
l
e
4
.
C
o
n
s
e
q
u
e
n
c
e
s
o
f
t
h
e
a
t
t
e
m
p
t
e
d
s
u
i
c
i
d
e
a
n
d
c
a
r
e
i
n
t
h
e
S
U
P
R
E
-
M
I
S
S
s
i
t
e
s
(
%
r
o
u
n
d
e
d
)
C
a
m
p
i
n
a
s
C
h
e
n
n
a
i
C
o
l
o
m
b
o
D
u
r
b
a
n
H
a
n
o
i
K
a
r
a
j
T
a
l
l
i
n
n
Y
u
n
c
h
e
n
g
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
P
h
y
s
i
c
a
l
c
o
n
s
e
q
u
e
n
c
e
s
(
n
=
5
7
)
(
n
=
1
0
2
)
(
n
=
3
3
1
)
(
n
=
3
4
9
)
(
n
=
4
7
2
)
(
n
=
5
8
7
)
(
n
=
1
5
3
)
(
n
=
4
0
2
)
(
n
=
8
8
)
(
n
=
2
1
3
)
(
n
=
3
9
6
)
(
n
=
5
4
9
)
(
n
=
1
6
0
)
(
n
=
3
0
8
)
(
n
=
3
9
)
(
n
=
8
1
)
N
o
n
e
1
8
2
8
0
0
1
6
2
0
2
0
1
8
6
8
1
1
1
2
3
3
0
0
M
i
x
a
3
0
3
5
2
5
3
4
4
7
5
2
7
7
7
6
6
5
8
1
7
4
7
7
5
3
5
9
3
3
2
0
Y
e
s
b
5
3
3
7
7
5
6
6
3
7
2
8
4
6
3
0
1
1
1
5
1
1
4
4
3
7
6
7
8
0
R
e
f
e
r
r
a
l
(
n
=
2
8
)
(
n
=
4
3
)
(
n
=
3
3
1
)
(
n
=
3
4
6
)
(
n
=
4
2
4
)
(
n
=
5
6
0
)
(
n
=
1
3
3
)
(
n
=
3
5
7
)
(
n
=
8
8
)
(
n
=
2
1
3
)
(
n
=
3
9
2
)
(
n
=
5
5
3
)
(
n
=
1
4
1
)
(
n
=
2
7
4
)
(
n
=
3
9
)
(
n
=
8
1
)
N
o
n
e
7
9
9
8
9
8
6
2
6
7
1
2
1
2
7
4
8
2
4
8
4
7
1
6
2
8
9
7
9
9
G
e
n
e
r
a
l
h
e
a
l
t
h
c
a
r
e
6
8
7
9
0
0
9
7
2
4
7
5
4
0
4
2
2
8
2
0
0
0
P
s
y
c
h
i
a
t
r
i
c
c
a
r
e
2
1
5
2
2
3
0
2
6
8
6
8
4
1
9
1
3
6
5
5
5
5
0
3
1
P
r
i
v
a
t
e
4
7
0
0
0
0
1
1
0
0
6
6
1
2
0
0
M
,
M
a
l
e
;
F
,
f
e
m
a
l
e
.
a
M
i
x
,

M
e
d
i
c
a
l
a
t
t
e
n
t
i
o
n
/
s
u
r
g
e
r
y
r
e
q
u
i
r
e
d
,
b
u
t
n
o
d
a
n
g
e
r
t
o
l
i
f
e
.
b

M
e
d
i
c
a
l
a
t
t
e
n
t
i
o
n
/
s
u
r
g
e
r
y
r
e
q
u
i
r
e
d
,
h
a
d
/
h
a
s
d
a
n
g
e
r
t
o
l
i
f
e

.
Suicide attempts in developing countries’ emergency care 1471
74
Consequences of the attempted suicide and care
The suicide attempt resulted in physical conse-
quences 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 (80
.
2% of
the 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 the
remaining sites, most subjects required a
combination of medical attention or surgery,
but there was no danger to life (Table 4).
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
(between 0% and 8% of the cases), with the
exception of Campinas (23
.
9% for women) and
Tallinn (34% for men).
Practically no referral to any professional
service was made in Yuncheng for both men
(97
.
4%) and women (98
.
8%) and in Chennai
(97
.
6% for men, 98
.
3% for women), which
reflects the non-existence of eligible referral
services in these locations. In Hanoi, Colombo
and Karaj the amount of non-referral was
equally dominant among both men and women
(46
.
5–81
.
7%). In Campinas referral was pri-
marily made to a general health-care or primary
health-care centre (67
.
9–79
.
1%, both sexes).
In Durban and Tallinn, the patients were
mainly sent to a psychiatric out-patient clinic
(50
.
4–85
.
7%, both sexes). In four of the eight
sites less than one-third of subjects received any
type of referral for follow-up evaluation or
care (Table 4).
A separate question regarding the acceptance
of an offer of professional care, which was not
linked to the referral, was answered positively
by the majority of subjects, i.e. they would ac-
cept to go to the consultation offered. Refusals
were strongest in Colombo (up to 38
.
5% for
females).
DISCUSSION
This is the first study to provide detailed infor-
mation on cases of suicide attempts from a wide
range of developing countries. For several of
the participating countries, it is the first data on
attempted suicides ever collected or published
both in national and international periodicals.
The situation in virtually all participating
emergency settings is such that suicide attempts
are not recorded on a routine basis, resulting
in a lack of data to estimate rates of suicide
attempts. An effort was made to collect for
the first time this basic intake information from
all suicide attempters in the emergency-care
settings.
Despite careful preparations, in some sites a
few subjects managed to slip through. In some
sites the number was not known (although be-
lieved to be very small), in other sites at least
sex and age of those not completing the intake
were known (allowing a comparison of those
who did and did not participate in the intake),
and in a third group of sites all subjects were
part of the intake. Future thorough analyses
specifically addressing sample issues will pro-
vide a sense of how representative the reported
cases are.
This sample of attempted suicides identi-
fied in emergency rooms of hospitals in eight
developing countries is, like those identified in
developed countries (Diekstra, 1993; Schmidtke
et al. 1996; Latha et al. 1996; Thanh et al. 2005),
primarily composed of young adults. The
male : female gender ratio in the eight countries
ranged from 1 : 1
.
1 to 1 : 2
.
6 which is similar to
that reported in the WHO/EURO multicentre
study [1 : 0
.
7 to 1 : 2
.
3 (Schmidtke et al. 2004)].
Unlike reports from developed countries (Lo¨ hr
& 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 protective factor for suicide attempt
in developing countries (WHO, 2002b).
Similar to other countries, self-poisoning is
the most common method of suicide attempt,
and the ingestion of pesticides, medications
or other poisons accounted for 69–98% of all
suicide attempts identified in the emergency-
care units of the eight sites included in the
study. Nevertheless, pesticides are a more
common method of self-poisoning in develop-
ing countries, particularly in China, India, and
Sri Lanka.
These findings strongly support earlier re-
ports on the role of pesticide poisoning in
attempted and completed suicide in developing
countries (Latha et al. 1996; Eddleston, 2000;
Phillips & Li, 2002; Phillips et al. 2002; Gunnell
& Eddleston, 2003; Eddleston & Phillips, 2004).
1472 A. Fleischmann et al.
75
It has been shown repeatedly that restricting
the access to and the availability of the prevail-
ing method can be effective in reducing the
frequency of suicide attempts (Bowles, 1995;
Roberts et al. 2003).
This result calls for immediate action on this
issue, where it is relevant, including the analysis
of regulations, distribution, availability, access,
and packaging of these substances, and for
prompt intervention after the intoxication, with
local emphasis on the most used substance, e.g.
pesticides in these Asian countries.
Another important finding was the relative
lack of professional services for referral of
suicide attempters. This results in a situation
where the care is limited to somatic symptoms
only. Even in those places where psychological
or psychiatric services were available, psy-
chiatric assessment and referral were not
delivered in a systematic way or as part of a
routine which is in agreement with a study from
Europe regarding young suicide attempters
(Hulte´ n et al. 2000). In these places, the current
situation leaves plenty of room for improvement
of the health services.
Accurate, standardized information on the
rates and characteristics of medically treated
suicide attempts is essential to the development
and evaluation of preventive services, however,
the emergency departments of hospitals in both
developed and less-developed countries are
not currently able to collect this information.
Our study has highlighted several of the diffi-
culties that need to be overcome to rectify this
problem: incomplete or inaccurate registration
of persons seen in emergency departments;
patients and family members intentionally mis-
reporting the cause of the attempted suicide
injury or absconding from the emergency de-
partment as soon as possible to avoid stigma
(Wasserman, 2001) and (in some cases) legal
sanctions; clinicians not recording routinely
suicide attempts as such and, therefore, failing
to collect essential information or to provide
follow-up referrals, or (in some cases) because
they wish to avoid legal proceedings. The mag-
nitude and causes of the problems vary across
the countries included in this study, largely
due to cultural and socio-economic factors.
Rectifying these problems will require sub-
stantial legal, administrative and attitudinal
changes.
ACKNOWLEDGEMENTS
The study was funded by the Department of
Mental Health and Substance Abuse, World
Health Organization, where both first authors
are employed. Some field research sites obtained
additional funding from the following agencies.
Hanoi : Swedish International Cooperation
Development Agency (SIDA), Stockholm,
Sweden [within the collaboration between the
Swedish National and Stockholm County
Council’s Centre for Suicide Research and
Prevention of Mental Ill-Health (NASP) at the
Institute for Psychosocial Medicine (IPM) and
the Department of Public Health Sciences at
the Karolinska Institute and Hanoi Medical
University]. Karaj : Iran National Research
Center for Medical Sciences, Tehran, Iran.
Tallinn: Estonian Health Insurance Fund,
Tallinn, Estonia; the Swedish National and
Stockholm County Council’s Centre for Suicide
Research and Prevention of Mental Ill-Health
(NASP) at the Institute for Psychosocial
Medicine (IPM) and the Department of Public
Health Sciences at the Karolinska Institute,
Stockholm, Sweden.
DECLARATION OF INTEREST
None.
REFERENCES
Bowles, J. R. (1995). An example of a suicide prevention program
in a developing country. In Preventive Strategies on Suicide
(ed. R. F. W. Diekstra, W. Gulbinat, I. Kienhorst and D. De Leo),
pp. 173–206. Brill : Leiden.
Diekstra, R. F. W. (1993). The epidemiology of suicide and para-
suicide. Acta Psychiatrica Scandinavica (Suppl.) 371, 9–20.
Eddleston, M. (2000). Patterns and problems of deliberate self-
poisoning in the developing world. QJM Monthly Journal of the
Association of Physicians 93, 715–731.
Eddleston, M. & Phillips, M. R. (2004). Self poisoning with
pesticides. British Medical Journal 328, 42–44.
Gunnell, D. & Eddleston, M. (2003). Suicide by intentional ingestion
of pesticides; a continuing tragedy in developing countries.
International Journal of Epidemiology 32, 902–909.
Hulte´ n, A., Wasserman, D., Hawton, K., Jiang, G. X., Salander-
Renberg, E., Schmidtke, A., Bille-Brahe, U., Bjerke, T., Kerkhof,
A., Michel, K. & Querejeta, I. (2000). Recommended care for
young people (15–19 years) after suicide attempts in certain
European countries. European Child and Adolescent Psychiatry
9, 100–108.
Kerkhof, A., Bernasco, W., Bille-Brahe, U., Platt, S. & Schmidtke, A.
(1999). European Parasuicide Study Interview Schedule (EPSIS).
In Facts and Figures: WHO/EURO (ed. U. Bille-Brahe). WHO
Regional Office for Europe: Copenhagen.
Latha, K. S., Bhat, S. M. & D’Souza, P. (1996). Suicide attempters
in a general hospital unit in India: their socio-demographic
Suicide attempts in developing countries’ emergency care 1473
76
and clinical profile – emphasis on cross-cultural aspects. Acta
Psychiatrica Scandinavica 94, 26–30.
Lo¨ hr, C. & Schmidtke, A. (2004). Marital relations of suicide
attempters. In Suicidal Behaviour: Theories and Research Findings
(ed. D. De Leo, U. Bille-Brahe, A. Kerkhof and A. Schmidtke).
Hogrefe & Huber: Go¨ ttingen.
Phillips, M. R. & Li, X. (2002). Suicide rates in China, 1995–99.
Lancet 359, 835–840.
Phillips, M. R., Yang, G., Zhang, Y., Wang, L., Ji, H. & Zhou, M.
(2002). Risk factors for suicide in China: a national case-control
psychological autopsy study. Lancet 360, 1728–1736.
Platt, S., Bille-Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T.,
Crepet, P., De Leo, D., Haring, C., Lonnqvist, J., Michel, K.,
Philippe, A., Pommereau, X., Querejeta, I., Salander-Renberg, E.,
Temesvary, B., Wasserman, D. & Sampaio-Faria, J. G. (1992).
Parasuicide in Europe: the WHO/EURO multicentre study on
parasuicide. I. Introduction and preliminary analysis for 1989.
Acta Psychiatrica Scandinavica 85, 97–104.
Roberts, D. M., Karunarathna, A., Buckley, N. A., Manuweera, G.,
Sheriff, M. H. R. & Eddleston, M. (2003). Influence of pesticide
regulation on acute poisoning deaths in Sri Lanka. Bulletin of the
World Health Organization 81, 1–10.
Schmidtke, A., Bille-Brahe, U., De Leo, D. & Kerkhof, A. (eds).
(2004). Suicidal behaviour in Europe: Results from the WHO/
EURO Multicentre Study on Suicidal Behaviour. Hogrefe &
Huber: Go¨ ttingen.
Schmidtke, A., Bille-Brahe, U., De Leo, D., Kerkhof, A., Bjerke, T.,
Crepet, P., Haring, C., Hawton, K., Lonnqvist, J., Michel, K.,
Pommereau, X., Querejeta, I., Philipe, I., Salander-Renberg, E.,
Temesvary, B., Wasserman, D., Fricke, S., Weinacker, B. &
Sampaio-Faria, J. G. (1996). Attempted suicide in Europe: rates,
trends and sociodemographic characteristics of suicide attempters
during the period 1989–1992. Results of the WHO/EURO
Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica
93, 327–338.
Thanh, H. T. T., Jiang, G. X., Van, T. N., Minh, D. P. T.,
Rosling, H. & Wasserman, D. (2005). Attempted suicide in Hanoi,
Vietnam. Social Psychiatry and Psychiatric Epidemiology 40,
64–71.
United Nations Department for Policy Coordination and Sustainable
Development (1996). Prevention of Suicide. Guidelines for the
Formulation and Implementation of National Strategies. United
Nations: New York.
Wasserman, D. (2001). Suicide: An Unnecessary Death. Dunitz:
London.
WHO (2002a). Multisite Intervention Study on Suicidal Behaviours
SUPRE-MISS: Protocol of SUPRE-MISS. World Health
Organization: Geneva.
WHO (2002b). World Report on Violence and Health. World Health
Organization: Geneva.
WHO (2003). The World Health Report 2003: Shaping the Future.
World Health Organization: Geneva.
1474 A. Fleischmann et al.
II
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 severity
of suicide attempt
MERIKE SISASK, AIRI VA
¨
RNIK, KAIRI KO
˜
LVES, KENN KONSTABEL,
DANUTA WASSERMAN
Sisask M, Va¨rnik A, Ko˜ lves 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 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. 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 suicide attempters
measured 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-being
index (WHO-5) in suicide risk assessment. The data on suicide attempters (n�469) was
obtained in Estonia (Tallinn) by the WHO Suicide Prevention*Multisite Intervention Study on
Suicidal Behaviours (SUPRE-MISS) methodology. Different psychometric scales were used to
measure suicidal intent (Pierce Suicidal Intent Scale) and emotional status (Beck Depression
Inventory for depression, Beck Hopelessness Scale for hopelessness, WHO-5 for well-being). All
psychometric scales correlated well with each other (PB0.05). Low level of well-being associated
with high level of suicidal intent, depression and hopelessness. Suicidal intent correlated the
most strongly with well-being. Analysis by gender and age groups revealed also significant
correlations with two exceptions only: correlation between suicidal intent and hopelessness did
not 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, can
be used in settings without psychological/psychiatric expertise in preliminary suicide risk
assessment.
’ Depression, Hopelessness, Severity of suicide attempt, Suicidal intent, Well-being.
Merike Sisask, Estonian-Swedish Mental Health and Suicidology Institute, O
˜
ie 39, Tallinn
11615, Estonia, E-mail: merike.sisask@neti.ee; Accepted 5 December 2007.
S
uicide 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 scales
in 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 with
lack 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 research
of 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 of
our 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 sensitive
and 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 suicide
attempters 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 Methods
Data collection
In 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 of
SUPRE-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-care
settings 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-depth
interview was conducted as soon as their medical
condition had stabilised. The interviewers were clinically
experienced specialists (psychiatrists and psychologists).
Description of subjects
The 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 males
31.5911.8 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%).
Scales
For 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 score
refers 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 analysis
The 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 significance
was set at a�0.05.
Results
The 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 impaired
emotional 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).
Discussion
As 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. T
a
b
l
e
1
.
M
e
a
n
s
c
o
r
e
s
o
f
d
i
f
f
e
r
e
n
t
s
c
a
l
e
s

l
l
e
d
i
n
a
f
t
e
r
s
u
i
c
i
d
e
a
t
t
e
m
p
t
(
t
o
t
a
l
,
b
y
g
e
n
d
e
r
a
n
d
a
g
e
g
r
o
u
p
s
)
.
G
e
n
d
e
r
A
g
e
g
r
o
u
p
T
o
t
a
l
(
s
)
M
a
l
e
s
(
9
s
)
F
e
m
a
l
e
s
(
9
s
)
t
-
t
e
s
t
P
-
v
a
l
u
e
1
5

2
4
(
9
s
)
2
5

3
9
(
9
s
)
4
0

(
9
s
)
F
P
-
v
a
l
u
e
P
S
I
S
8
.
2
4
(
9
4
.
4
2
)
8
.
0
1
(
9
4
.
5
4
)
8
.
3
7
(
9
4
.
3
6
)

0
.
8
3
8
0
.
4
0
2
7
.
5
2
(
9
4
.
2
2
)
8
.
2
1
(
9
4
.
2
0
)
9
.
2
5
(
9
4
.
7
5
)
5
.
9
5
9
0
.
0
0
3
B
D
I
1
8
.
9
0
(
9
1
1
.
3
5
)
1
7
.
6
8
(
9
1
0
.
7
3
)
1
9
.
5
3
(
9
1
1
.
6
3
)

1
.
6
7
5
0
.
0
9
5
1
5
.
7
8
(
9
1
1
.
1
4
)
2
0
.
0
1
(
9
1
0
.
4
1
)
2
1
.
7
3
(
9
1
1
.
7
8
)
1
2
.
1
8
8
B
0
.
0
0
1
W
H
O
-
5
1
0
.
1
1
(
9
5
.
5
9
)
1
0
.
7
1
(
9
5
.
3
6
)
9
.
7
9
(
9
5
.
6
8
)
1
.
6
9
9
0
.
0
9
0
1
1
.
3
6
(
9
5
.
6
8
)
9
.
9
3
(
9
4
.
7
8
)
8
.
6
3
(
9
6
.
0
1
)
9
.
4
8
5
B
0
.
0
0
1
B
H
S
/
m
u
l
t
i
9
.
3
5
(
9
5
.
5
4
)
9
.
6
9
(
9
5
.
4
1
)
9
.
1
8
(
9
5
.
6
1
)
0
.
9
3
9
0
.
3
4
8
7
.
8
5
(
9
5
.
2
7
)
9
.
7
1
(
9
5
.
4
6
)
1
0
.
9
7
(
9
5
.
5
1
)
1
2
.
8
5
4
B
0
.
0
0
1
B
H
S
/
o
n
e
0
.
5
1
(
9
0
.
5
0
)
0
.
5
4
(
9
0
.
5
0
)
0
.
4
9
(
9
0
.
5
0
)
0
.
2
2
0
0
.
2
8
5
0
.
4
0
(
9
0
.
4
9
)
0
.
5
3
(
9
0
.
5
0
)
0
.
6
3
(
9
0
.
4
8
)
8
.
9
9
2
B
0
.
0
0
1
P
S
I
S
,
P
i
e
r
c
e
S
u
i
c
i
d
a
l
I
n
t
e
n
t
S
c
a
l
e
;
B
D
I
,
B
e
c
k
D
e
p
r
e
s
s
i
o
n
I
n
v
e
n
t
o
r
y
;
W
H
O
-
5
,
W
H
O
w
e
l
l
-
b
e
i
n
g
i
n
d
e
x
;
B
H
S
/
m
u
l
t
i
,
B
e
c
k
H
o
p
e
l
e
s
s
n
e
s
s
S
c
a
l
e
(
m
u
l
t
i
p
l
e
-
i
t
e
m
)
;
B
H
S
/
o
n
e
,
B
e
c
k
H
o
p
e
l
e
s
s
n
e
s
s
S
c
a
l
e
(
o
n
e
-
i
t
e
m


M
y
f
u
t
u
r
e
s
e
e
m
s
d
a
r
k
t
o
m
e


)
.
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 not
necessarily 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.
Conclusions
The current study demonstrated that in understanding
the 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 loaded
scales 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 experience
obtained during the participation of the authors in the WHO Multisite
Intervention Study on Suicidal Behaviours (SUPRE-MISS), a project
funded by the World Health Organisation and the participating field
research centres.
The Tallinn centre obtained additional funding for data collection
and analysis from the following agencies: the Estonian Health
Insurance Fund; the Swedish National and Stockholm County
Council’s Centre for Suicide Research and Prevention of Mental Ill-
Health (NASP), the WHO Lead Collaborating Centre at the
Department of Public Health Sciences, the Karolinska Institute and
the 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. Va¨rnik, 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-MISS
study.
A list of other staff contributing to the project can be obtained from
WHO, Geneva.
References
1. Bech P, Raabaek Olsen L, Nimeus A. Psychometric scales in
suicide risk assessment. In: Wasserman D, editor. Suicide: An
unnecessary death. London: Martin Dunitz; 2001. p. 147�57.
2. Watson D, Goldney R, Fisher L, Merritt M. The measurement of
suicidal ideation. Crisis 2001;22:12�4.
3. Beck AT, Schuyler D, Herman I. Development of Suicidal Intent
Scales. In: Beck AT, Resnick HLP, Lettieri DJ, editors. The
prediction of suicide. Bowie, MD: Charles Press; 1974. p. 45�56.
Table 2. Correlations between different scales filled in after
suicide 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�24
BDI 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�39
BDI 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-
lessness Scale (one-item ‘‘My future seems dark to me’’).
M SISASK ET AL.
434 NORD J PSYCHIATRY×VOL 62×NO 6×2008
83
4. Pierce DW. Suicidal intent in self-injury. Br J Psychiatry 1977;130:
377�85.
5. Mo¨ ller HJ. Suicide, suicidality and suicide prevention in affective
disorders. Acta Psychiatr Scand Suppl 2003;(418):73�80.
6. Wasserman D. Affective disorders and suicide. In: Wasserman D,
editor. Suicide: An unnecessary death. London: Martin Dunitz;
2001. p. 39�47.
7. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An
inventory for measuring depression. Arch Gen Psychiatry 1961;4:
561�71.
8. Beck AT, Weissman A, Lester D, Trexler L. The measurement of
pessimism: The hopelessness scale. J Consult Clin Psychol 1974;42:
861�5.
9. MacLeod AK, Tata P, Tyrer P, Schmidt U, Davidson K,
Thompson S. Hopelessness and positive and negative future
thinking in parasuicide. Br J Clin Psychol 2005;44(Pt 4):495�504.
10. Aish AM, Wasserman D. Does Beck’s Hopelessness Scale really
measure several components? Psychol Med 2001;31:367�72.
11. Beck AT, Steer RA, Beck JS, Newman CF. Hopelessness, depres-
sion, suicidal ideation, and clinical diagnosis of depression. Suicide
Life Threat Behav 1993;23:139�45.
12. Beck AT, Weishaar ME. Suicide risk assessment and prediction.
Crisis 1990;11:22�30.
13. Brezo J, Paris J, Turecki G. Personality traits as correlates of
suicidal ideation, suicide attempts, and suicide completions: A
systematic review. Acta Psychiatr Scand 2006;113:180�206.
14. Kuo WH, Gallo JJ, Eaton WW. Hopelessness, depression,
substance disorder, and suicidality*A 13-year community-based
study. Soc Psychiatry Psychiatr Epidemiol 2004;39:497�501.
15. Beck AT, Kovacs M, Weissman A. Hopelessness and suicidal
behavior. An overview. JAMA 1975;234:1146�9.
16. Dyer JA, Kreitman N. Hopelessness, depression and suicidal intent
in parasuicide. Br J Psychiatry 1984;144:127�33.
17. Bray I, Gunnell D. Suicide rates, life satisfaction and happiness as
markers for population mental health. Soc Psychiatry Psychiatr
Epidemiol 2006;41:333�7.
18. WHO. Info Package: Mastering depression in primary care.
Fredriksborg: World Health Organisation, Regional Office for
Europe, Psychiatric Research Unit; 1998.
19. Henkel V, Mergl R, Kohnen R, Maier W, Mo¨ ller HJ, Hegerl U.
Identifying depression in primary care: A comparison of different
methods 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 list
in suicide risk. Practical guideline for dealing with depression].
MMW Fortschr Med 2003;145:24�7.
22. Lo¨we B, Spitzer RL, Gra¨fe K, Kroenke K, Quenter A, Zipfel S, et
al. Comparative validity of three screening questionnaires for
DSM-IV depressive disorders and physicians’ diagnoses. J Affect
Disord 2004;78:131�40.
23. Heun R, Burkart M, Maier W, Bech P. Internal and external
validity of the WHO Well-Being Scale in the elderly general
population. Acta Psychiatr Scand 1999;99:171�8.
24. Bech P, Olsen LR, Kjoller M, Rasmussen NK. Measuring
well-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 in
outpatients 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 elderly
community 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 in
emergency-care settings of general hospitals in eight low- and
middle-income countries. Psychol Med 2005;35:1467�74.
28. WHO. Multisite Intervention Study on Suicidal Behaviours
SUPRE-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: Lewis
M, Haviland-Jones JM, editors. Handbook of emotions, 2nd
edition. New York: Guilford Press; 2000. p. 325�37.
31. Huppert FA, Baylis N. Well-being: Towards an integration of
psychology, neurobiology and social science. Phil Trans R Soc
Lond, B. Biol Sci 2004;359:1447�51.
32. Helliwell JF, Putnam RD. The social context of well-being. Phil
Trans R Soc Lond, B. Biol Sci 2004;359:1435�46.
33. Huppert FA, Baylis N, Keverne B. Introduction: Why do we need a
science of well-being? Phil Trans R Soc Lond, B. Biol Sci 2004;359:
1331�2.
34. Bech P, Raabaek Olsen L, Nimeus A. Psihometritsheskije shkalo˜
otsenki suicidalnogo riska. In: Wasserman D, editor. Suitsid*
naprasnaja smert. Tartu: Tartu U
¨
likooli Kirjastus; 2003. p. 157�63.
35. Henkel V, Mergl R, Coyne JC, Kohnen R, Mo¨ ller HJ, Hegerl U.
Screening for depression in primary care: Will one or two items
suffice? Eur Arch Psychiatry Clin Neurosci 2004;254:215�23.
36. Henkel V, Mergl R, Kohnen R, Allgaier AK, Mo¨ ller HJ, Hegerl U.
Use of brief depression screening tools in primary care: Con-
sideration of heterogeneity in performance in different patient
groups. Gen Hosp Psychiatry 2004;26:190�8.
37. Primack BA. The WHO-5 Wellbeing Index performed the best in
screening for depression in primary care. ACP J Club 2003;139:48.
Merike Sisask, Estonian-Swedish Mental Health and Suicidology
Institute, Tallinn, Estonia; Tallinn University, Estonia.
Airi Va¨rnik, Estonian-Swedish Mental Health and Suicidology
Institute, Tallinn, Estonia; Tallinn University, Estonia; University of
Tartu, Estonia.
Kairi Ko˜ lves, Estonian-Swedish Mental Health and Suicidology
Institute, Tallinn, Estonia.
Kenn Konstabel, University of Tartu, Estonia; National Institute for
Health Development, Tallinn, Estonia.
Danuta Wasserman, National Prevention of Suicide and Mental
Ill-Health (NASP) at Karolinska Institute and Stockholm Country
Council’s Centre for Suicide Research and Prevention, WHO Lead
Collaborating Centre of Mental Health Problems and Suicide Across
Europe, Stockholm, Sweden.
WELL-BEING AND SEVERITY OF SUICIDE ATTEMPT
NORD J PSYCHIATRY×VOL 62×NO 6×2008 435
III
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.
87
M. Sisask et al.: Attempted Suicide and Suicidal Intent Crisis 2009; Vol. 30(3):136–143 © 2009 Hogrefe Publishing
Research Trends
Severity of Attempted Suicide
as Measured by the
Pierce Suicidal Intent Scale
Merike Sisask
1,2
, Kairi Kõlves
1,3
, and Airi Värnik
1,2,4,5
1
Estonian-Swedish Mental Health and Suicidology Institute, Estonian Centre of Behavioral and Health
Sciences, Tallinn, Estonia,
2
Tallinn University, Tallinn, Estonia,
3
Australian Institute for Suicide Research
and Prevention (AISRAP), Brisbane, Australia,
4
University of Tartu, Tartu, Estonia,
5
National Prevention
of Suicide and Mental Ill-Health (NASP) at Karolinska Institute and StockholmCounty Council’s Centre
for Suicide Research and Prevention, WHOLead 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 need
for further evidence has been pointed out. Aims: The aim of the present study was to characterize the severity of attempted suicide by
extracting components of suicidal intent and analyzing levels of suicidal intent by gender, age, and variables indicating the severity of
attempted 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 intent
was not gender-dependent, but rose with age. Males and females were also similar in terms of discrete components. Classified in age
groups, 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, method
of attempting suicide, and duration of hospitalization were linked to suicidal intent, but danger to life as assessed by interviewers was
not. Conclusions: In suicide-risk assessment, results from a Suicidal Intent Scale contribute to clinical observation and add valuable
information about a suicidal person’s real intention.
Keywords: suicide attempt, Pierce Suicidal Intent Scale, components of suicidal intent, gender and age differences
Introduction
Suicidal intent is an essential component of any definition
of suicide and suicidal behavior. This is primarily because
it permits a distinction to be drawn between accidental and
suicidal behavior (Andriessen, 2006). Suicidal intent has
been defined as the seriousness or intensity of a person’s
wish to terminate his or her life (Beck, Schuyler, & Her-
man, 1974). The term level of suicidal intent is used to
describe 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 has
been described as a continuum from the lowest (weariness
of 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 froman 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 and
various aspects of suicidal intent. One of the best-known
scales, the Beck Suicide Intent Scale (BSIS), is not a sui-
cide-risk scale as such, but rather a scale designed for use
in research studies to classify suicide attempters (Bech,
Raabaek Olsen, & Nimeus, 2001; Beck, Kovacs, & Weiss-
man, 1979; Beck et al., 1974). A comparable scale, the
DOI 10.1027/0227-5910.30.3.136
Crisis 2009; Vol. 30(3):136–143 © 2009 Hogrefe Publishing
88
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 suicidal intent than the
BSIS, but the outcome was merely a modification.
Although some aspects and meanings of suicidal intent
have been studied, the results of various studies have been
controversial and the need for further evidence on this is-
sue, focusing particularly on nonfatal suicidal behavior and
gender-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 components
of suicidal intent and analyzing levels of suicidal intent by
gender, age, and variables indicating the severity of at-
tempted suicide.
Material and Methods
In 2000 the World Health Organization (WHO) launched
the worldwide intervention study on suicidal behavior
SUPRE-MISS (Suicide Prevention – Multisite Intervention
Study on Suicidal Behaviors). Its main objective was to
reduce the mortality and morbidity associated with suicidal
behavior. The study was conducted on five continents, and
one of the participating centers was Estonia (Tallinn). The
methodology of SUPRE-MISS was elaborated by a WHO
expert group and adapted to local conditions (Fleischmann
et 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 approved
the Estonian study. All suicide attempters identified by
medical staff in the emergency-care settings of the North-
ern Estonian Regional Hospital between December 2001
and January 2004 were invited to participate in the study.
Those who agreed filled in a consent form, and structured
in-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 attempters
seen at the emergency department during the study period.
Among the suicide attempters enrolled, females were
slightly 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 divided
into five age groups (Table 1).
For measuring suicidal intent, a revised version of the
original Pierce Suicidal Intent Scale (PSIS) was used
(Pierce, 1977; WHO, 2002). The scale consisted of 12
questions 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’s
α = 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 subjects
with one missing response were included in the analysis.
To characterize the severity of attempted suicide, the
following variables were chosen for analysis: psychiatric
disorders, method of attempting suicide, duration of hos-
pitalization after the suicide attempt, and interviewers’
assessment regarding the physical consequences of and
danger to life entailed by the suicide attempt. Interview-
ers coded psychiatric disorders and method of attempting
suicide according to the ICD-10. Psychiatric diagnoses
of 54 suicide attempters interviewed by psychologists
were missing. The group with missing diagnoses did not
differ 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 were
divided 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 was
categorized as: poisoning (X60– X69), sharp objects
(X78), and other (hard) methods. Duration of hospitaliza-
tion after the suicide attempt was calculated according to
the date and time of admission and discharge from the
hospital. 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
M. Sisask et al.: Attempted Suicide and Suicidal Intent 137
© 2009 Hogrefe Publishing Crisis 2009; Vol. 30(3):136–143
89
chosen: 1 day, 2 days, 3 days, 4–7 days, over 7 days.
Finally, the interviewers were asked to choose an answer
regarding the physical consequences and the danger to
life for the attempted suicide as given in the interview
form. 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 selected
in accordance with the nature of the variables. To extract
the factors of the PSIS, the procedure of principal com-
ponents with varimax rotation was used. Scores in terms
of single PSIS components were calculated on the basis
of variables combined as a single factor. Differences be-
tween mean scores were calculated using the t-test for
gender and analysis of variance (ANOVA) for age groups
and other variables. Spearman’s rank correlation coeffi-
cient was calculated to examine the relationships be-
tween gender, age, and PSIS components. The level of
statistical significance was set at p = .05.
Results
The PSIS variables were categorized as four factors that
described 62.1% of the total variance (Table 2). The first
factor, 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 and
nonverbal suicidal communication before the suicide at-
tempt. The third, Circumstances, determined the possibility
of intervention and prevention of fatal outcome. The fourth,
Alcohol/Drugs, specified whether the person had con-
sumed alcohol or drugs before the suicide attempt and
whether 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 differences
in mean total scores for suicidal intent. Analysis by age
groups, on the other hand, revealed statistically significant
differences in mean total scores of suicidal intent, and these
increased with age (Table 3).
Table 2. Factor analysis (principal component analysis with varimax rotation) of Pierce Suicidal Intent Scale (PSIS) filled
in 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 gender
and 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
138 M. Sisask et al.: Attempted Suicide and Suicidal Intent
Crisis 2009; Vol. 30(3):136–143 © 2009 Hogrefe Publishing
90
As for the mean total score, there were no statistically
significant gender differences in terms of single compo-
nents. For the age groups, differences in the mean scores
of the following components were statistically significant:
Arrangements, Circumstances, and Alcohol/Drugs (Table
3). Scores for Arrangements and Circumstances 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.
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 the
scores 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 attempters
with serious psychiatric diagnoses (affective disorders or
schizophrenia) 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 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. Suicide attempters who
stayed in the hospital for 3 days after the suicide attempt had
higher mean scores for suicidal intent than those whose hos-
pital stays were shorter or longer. There were no significant
differences in mean scores between the groups in terms of
physical consequences and danger to life, as assessed by the
interviewers (Table 5).
Discussion
Components of Suicidal Intent
As extracted in our study, the four different components of
suicidal 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 of
suicide 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.
M. Sisask et al.: Attempted Suicide and Suicidal Intent 139
© 2009 Hogrefe Publishing Crisis 2009; Vol. 30(3):136–143
91
ion about potential lethality of the act, termed a Wish to
Die; long-term preparations and suicidal communication,
termed Arrangements; short-term and immediate prepara-
tions, known as Circumstances; and the role played in the
current suicide attempt by alcohol and/or drug consump-
tion, expressed as Alcohol/Drugs. All these components
are important indicators in characterizing the nuances of
the suicidal process before the suicide attempt. To the best
of our knowledge, there has been no previous research on
a PSIS factor structure, although factor analyses of the
BSIS have been published. Diaz et al. (2003) carried out a
review 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 the
number of factors extracted varies from two to four, some
generalizations 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 suicidal
process has been recognized before (Lester, 2001; Wasser-
man, 2001), and these aspects also characterize 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 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: Some
have shown higher scores among males (Harriss, Hawton,
& Zahl, 2005; Haw, Hawton, Houston, & Townsend,
2003), but there are also studies showing higher scores
among females (Hamdi, Amin, & Mattar, 1991) or finding
no 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, significant
gender 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 carry
out 61% of suicide attempts (Sisask, 2005). There is also a
study asserting major gender differences in the course of
the suicidal process: The median interval from the first sui-
cidal communication to the suicide was found to be shorter
in men than in women (Runeson, Beskow, &Waern, 1996).
Based on these differences, it would be plausible to assume
that gender may play an important role in other aspects of
suicidal behavior, 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
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 sui-
cidal intent, although men chose more violent methods
(Denning et al., 2000).
The results of our study corroborated the studies that had
found no gender differences in suicidal intent. Evidently,
we must accept the fact that, despite epidemiological gen-
der differences, people who commit suicide and those who
make 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 of
suicidal intent rose with age. Suicidal intent has also been
found 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, some
studies have found that actual intent does not vary greatly
with age (Haw et al., 2003; Hjelmeland & 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 characterizing the preparations before
a suicide attempt (Arrangements and Circumstances)
showed that older people prepared their suicide attempt
more carefully and planned it in greater detail. Suicidal be-
havior, especially with a nonfatal outcome, is frequently a
communication act that is not prompted by any real wish
to 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 a
communicative nature among younger people, in particu-
lar: 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.
Another component of suicidal intent that was not found
to increase with age was Alcohol/Drugs. The role of alco-
hol or drugs in facilitating suicide attempts was largest
among the middle age groups. According to Kõlves, Vär-
nik, Tooding, & Wasserman (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 component of Alcohol/Drugs
140 M. Sisask et al.: Attempted Suicide and Suicidal Intent
Crisis 2009; Vol. 30(3):136–143 © 2009 Hogrefe Publishing
92
does not differentiate between alcohol abusers and non-
abusers, and results should, therefore, be interpreted with
care. It is known from a previous study that alcohol-de-
pendent suicide attempters obtain relatively low scores on
the Suicidal Intent Scale. But although these patients may
lack a strong wish to die, they are nonetheless at high risk
for 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 same
way in practice, given its inability to reflect the dynamic
nature of suicidal behavior (Lyons, Price, Embling, &
Smith, 2000). However, previous research has suggested
that the level of suicidal intent appears to be a powerful
predictor of eventual suicide after attempted suicide (Hjel-
meland, 1996; Niméus et al., 2002; Suominen, Isometsa,
Ostamo, & Lonnqvist, 2004). Although a higher level of
suicidal intent at the time of the suicide attempt has been
found to be a risk factor for possible future suicide, it has
been admitted that a Suicidal Intent Scale cannot forecast
which specific patients will die by suicide. Nevertheless,
information about suicidal intent is still valuable in clinical
suicide-risk assessment (Harriss & Hawton, 2005).
Other variables included in the analysis as possible char-
acteristics of the severity of suicide attempt (psychiatric
disorders, method of attempting suicide, duration of hospi-
talization, interviewer’s assessment on lethality) provide
some hints for discussion around the construct validity of
the PSIS. Psychiatric disorders have been clearly linked to
suicidal behavior (Joiner, Brown, & Wingate, 2005) and
the results of the present study did, indeed, confirm the role
of psychiatric disorders in the suicidal process. Suicide at-
tempters with serious psychiatric conditions, such as affec-
tive disorders (mainly depression) and schizophrenia, had
higher 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 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. Although poisoning has
been classified as a “soft” suicide method compared with
other methods (Spicer & Miller, 2000), the suicidal-intent
level of suicide attempters using poisoning has been shown
to 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 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-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 those
spending 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 had
lower mean scores for suicidal intent. It is very likely that
persons committing less severe suicide attempts spend up
to 2 days in the hospital, but no more. Suicide attempters
who stay in the hospital for long periods probably suffer
from complications they did not initially mean to provoke,
and this may explain their lower level of suicidal intent. 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 conse-
quences 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 attempt-
er, or the availability and effectiveness of healthcare ser-
vices.
One finding of our study was that interviewers did not
succeed in differentiating among suicide attempters ac-
cording to their level of suicidal intent while assessing the
physical 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’s
real intention more precisely than a clinician’s objectively
observed assessment of the potential lethality of the suicide
attempt (Watson, Goldney, Fisher, & Merritt, 2001).
Methodological Considerations
It is questionable whether the results of the present study
are comparable with other results from different studies on
suicidal intent. The first problem associated with compar-
ison is the potential variation in definitions and criteria used
for selecting research subjects (“attempted suicide,” “para-
suicide,” “serious suicide attempt,” “deliberate self-
harm”). Controversial results from different studies can
probably also be ascribed to disparate ways of measuring
suicidal intent. Methodologically uniform cross-cultural
comparison on this issue would be most welcome.
Conclusions
In conclusion, the present study demonstrated that, in the
Pierce Suicidal Intent Scale (PSIS), four components char-
acterizing the nuances of the suicidal process before at-
tempted suicide were very clearly differentiated. The level
of suicidal intent was not gender-dependent, but increased
with age. Males and females were also similar with respect
to individual components of suicidal intent. Although
scores for the unequivocally expressed Wish to Die com-
ponent were similar among all age groups, scores for more
equivocal communication (components termed Arrange-
ments and Circumstances) increased with age. The Alco-
M. Sisask et al.: Attempted Suicide and Suicidal Intent 141
© 2009 Hogrefe Publishing Crisis 2009; Vol. 30(3):136–143
93
hol/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 in-
terviewers’ assessment, there were no differences in level
of suicidal intent among groups of suicide attempters cat-
egorized in terms of the physical consequences and danger
to life owing to the suicide attempt. The level of suicidal
intent as measured by a Suicidal Intent Scale is valuable
information on suicidal person’s true intention and could
help clinical observation performed by a specialist in sui-
cide-risk assessment.
Acknowledgments
This paper is based on the data and experience obtained
during the authors’ participation in the WHO Multisite
Intervention Study on Suicidal Behaviors (SUPRE-MISS),
a project funded by the World Health Organization and the
participating field research centers.
The Tallinn center obtained additional funding from the
following agencies: The Estonian Health Insurance Fund;
the Swedish National and Stockholm County Council’s
Centre for Suicide Research and Prevention of Mental Ill-
Health (NASP) at the Institute for Psychosocial Medicine
(IPM), Department of Public Health Sciences, Karolinska
Institute; the Estonian Scientific Foundation (Project
No. 6799, “The role of alcohol in the suicide process and
in prevention of suicidal behavior,” and Project No. 7132,
“Suicide trend in Estonia during independence: What are
the associations with sociopolitical, economic, and public
health 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. Fleischmann
have 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 other
staff contributing to the project can be obtained from
WHO, 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.
References
Andriessen, K. (2006). On “intention” in the definition of suicide.
Suicide and Life-Threatening Behavior, 36, 533–538.
Beautrais, A.L. (2001). Suicides and serious suicide attempts:
Two populations or one? Psychological Medicine, 31,
837–845.
Bech, P., Raabaek Olsen, L., & Nimeus, A. (2001). Psychometric
scales in suicide risk assessment. In D. Wasserman (Ed.), Sui-
cide: An unnecessary death (pp. 147–157). London: Martin
Dunitz.
Beck, A.T., Kovacs, M., & Weissman, A. (1979). Assessment of
suicidal intention: The scale for suicide ideation. Journal of
Consulting and Clinical Psychology, 47, 343–352.
Beck, A.T., Schuyler, D., & Herman, I. (1974). Development of
suicidal intent scales. In A.T. Beck, H.L.P. Resnick, & D.J.
Lettieri (Eds.), The prediction of suicide (pp. 45–56). Bowie,
ML: Charles Press.
Denning, D.G., Conwell, Y., King, D., & Cox, C. (2000). Method
choice, intent, and gender in completed suicide. Suicide and
Life-Threatening Behavior, 30, 282–288.
Diaz, F.J., Baca-Garcia, E., Diaz-Sastre, C., Garcia Resa, E., Blas-
co, H., Braquehais Conesa, D. et al. (2003). Dimensions of
suicidal behavior according to patient reports. European Ar-
chives of Psychiatry and Clinical Neuroscience, 253, 197–202.
Dyer, J.A., &Kreitman, N. (1984). Hopelessness, depression, and
suicidal intent in parasuicide. British Journal of Psychiatry,
144, 127–133.
Farberow, N.L., &Shneidman, E.S. (1961). The cry for help. New
York: Blakiston Division.
Fleischmann, A., Bertolote, J.M., De Leo, D., Botega, N., Phillips,
M., Sisask, M. et al. (2005). Characteristics of attempted sui-
cides seen in emergency-care settings of general hospitals in
eight low- and middle-income countries. Psychological Med-
icine, 35, 1467–1474.
Hamdi, E., Amin, Y., & Mattar, T. (1991). Clinical correlates of
intent in attempted suicide. Acta Psychiatrica Scandinavica,
83, 406–411.
Harriss, L., & Hawton, K. (2005). Suicidal intent in deliberate
self-harm and the risk of suicide: The predictive power of the
Suicide Intent Scale. Journal of Affective Disorders, 86,
225–233.
Harriss, L., Hawton, K., & Zahl, D. (2005). Value of measuring
suicidal intent in the assessment of people attending hospital
following self-poisoning or self-injury. British Journal of Psy-
chiatry, 186, 60–66.
Haw, C., Hawton, K., Houston, K., & Townsend, E. (2003). Cor-
relates of relative lethality and suicidal intent among deliberate
self-harmpatients. Suicide and Life-Threatening Behavior, 33,
353–364.
Hawton, K. (2000). General hospital management of suicide at-
tempters. In K. Hawton & K. van Heeringen (Eds.), The inter-
national handbook of suicide and attempted suicide. New
York: Wiley.
Hjelmeland, H. (1995). Verbally expressed intentions of parasui-
cide: I. characteristics of patients with various intentions. Cri-
sis, 16, 176–181.
Hjelmeland, H. (1996). Verbally expressed intentions of parasui-
cide: II. Prediction of fatal and nonfatal repetition. Crisis, 17,
10–14.
Hjelmeland, H., & Hawton, K. (2004). Intentional aspects of non-
fatal suicidal behavior. In D. De Leo, U. Bille-Brahe, J.F. Kerk-
hof, & A. Schmidtke (Eds.), Suicidal behavior: Theories and
research findings (pp. 67–78). Göttingen: Hogrefe & Huber.
Hjelmeland, H., & Knizek, B.L. (1999). Conceptual confusion
about intentions and motives of nonfatal suicidal behavior: A
142 M. Sisask et al.: Attempted Suicide and Suicidal Intent
Crisis 2009; Vol. 30(3):136–143 © 2009 Hogrefe Publishing
94
discussion of terms employed in the literature of suicidology.
Archives of Suicide Research, 5, 275–281.
Hjelmeland, H., Knizek, B.L., & Nordvik, H. (2002). The com-
municative aspect of nonfatal suicidal behavior – Are there
gender differences? Crisis, 23, 144–155.
Hjelmeland, H., Nordvik, H., Bille-Brahe, U., De Leo, D., Kerk-
hof, J.F., Lonnqvist, J. et al. (2000). A cross-cultural study of
suicide intent in parasuicide patients. Suicide and Life-Threat-
ening Behavior, 30, 295–303.
Joiner, T.E., Jr., Brown, J.S., & Wingate, L.R. (2005). The psy-
chology and neurobiology of suicidal behavior. Annual Review
of Psychology, 56, 287–314.
Kõlves, K., Värnik, A., Tooding, L.M., & Wasserman, D. (2006).
The role of alcohol in suicide: A case-control psychological
autopsy study. Psychological Medicine, 36, 923–930.
Lester, D. (2001). Nonfatal suicidal behavior as a communication.
Crisis, 22, 49–51.
Lyons, C., Price, P., Embling, S., & Smith, C. (2000). Suicide risk
assessment: A review of procedures. Accident and Emergency
Nursing, 8, 178–186.
Maris, R.W., Berman, A.L., Silverman, M.M., & Bongar, B.M.
(2000). Comprehensive textbook of suicidology. New York:
Guilford.
Michel, K., Valach, L., & Waeber, V. (1994). Understanding de-
liberate self-harm: The patients’ views. Crisis, 15, 172–178.
Nielsen, A.S., Stenager, E., &Brahe, U.B. (1993). Attempted sui-
cide, suicidal intent, and alcohol. Crisis, 14, 32–38.
Niméus, A., Alsén, M., & Träskman-Bendz, L. (2002). High sui-
cidal intent scores indicate future suicide. Archives of Suicide
Research, 6, 211–219.
Pierce, D.W. (1977). Suicidal intent in self-injury. British Journal
of Psychiatry, 130, 377–385.
Runeson, B.S., Beskow, J., & Waern, M. (1996). The suicidal
process in suicides among young people. Acta Psychiatrica
Scandinavica, 93, 35–42.
Schmidtke, A., Weinacker, B., Löhr, C., Bille-Brahe, U., De Leo,
D., Kerkhof, A. et al. (2004). Suicide and suicide attempts in
Europe. In A. Schmidtke, U. Bille-Brahe, D. De Leo, & A.
Kerkhof (Eds.), Suicidal behavior in Europe (pp. 15–28).
Cambridge/Göttingen: Hogrefe & Huber.
Sisask, M. (2005). Suitsidaalsus ühiskonnas ning suitsiidikatse
sotsiaal-demograafilised, meditsiinilised ja psüühilised mõju-
rid [Suicidality in the community and sociodemographic, med-
ical, and psychic factors of attempted suicide]. Tartu: Tartu
Ülikool, Tervishoiu Instituut.
Skegg, K. (2005). Self-harm. Lancet, 366, 1471–1483.
Spicer, R.S., & Miller, T.R. (2000). Suicide acts in eight states:
Incidence and case fatality rates by demographics and method.
American Journal of Public Health, 90, 1885–1891.
Suominen, K., Isometsa, E., Ostamo, A., & Lonnqvist, J. (2004).
Level of suicidal intent predicts overall mortality and suicide
after attempted suicide: A 12-year follow-up study. BMC Psy-
chiatry, 4, 11.
Wasserman, D. (2001). A stress-vulnerability model and the devel-
opment of the suicidal process. In D. Wasserman (Ed.), Suicide:
An unnecessary death (pp. 13–27). London: Martin Dunitz.
Watson, D., Goldney, R., Fisher, L., & Merritt, M. (2001). The
measurement of suicidal ideation. Crisis, 22, 12–14.
WHO. (2002). Multisite Intervention Study on Suicidal Behaviors
SUPRE-MISS: Protocol of SUPRE-MISS. Geneva: WHO.
Värnik, A., Kõlves, K., & Wasserman, D. (2005). Suicide among
Russians in Estonia: Database study before and after independ-
ence. British Medical Journal, 330, 176–177.
About the authors
Merike Sisask, MSc, Executive Director and Researcher at the
Estonian-Swedish Mental Health and Suicidology Institute
(ERSI), has a bachelor’s degree in law (1991) and has worked as
a psychological counselor (2003). She also holds a master’s de-
gree in public health (2005) and is presently a PhD student in
sociology at Tallinn University (2006–2010).
Kairi Kõlves, PhD, is Researcher at the the Estonian-Swedish
Mental Health and Suicidology Institute (ERSI). She holds a
bachelor’s degree (1999), a master’s degree (2001), and a doctoral
degree (2006) in sociology from the University of Tartu. She is
presently Research Fellow at the Australian Institute for Suicide
Research and Prevention (AISRAP, 2008/2009).
Airi Värnik, MD, PhD, is founder and Director of the Estonian-
Swedish Mental Health and Suicidology Institute (ERSI). She
holds 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 of
Suicide Research.
Merike Sisask
Õie 39
Tallinn 11615
Estonia
Tel./Fax +372 651 6550
E-mail merike.sisask@neti.ee
M. Sisask et al.: Attempted Suicide and Suicidal Intent 143
© 2009 Hogrefe Publishing Crisis 2009; Vol. 30(3):136–143
IV
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.
97
Is Religiosity a Protective
Factor Against Attempted
Suicide: A Cross-Cultural
Case-Control Study
Merike Sisask, Airi Va¨rnik, Kairi Ko˜ lves, 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 dimensions
has a protective effect against attempted suicide. Community controls (n ¼5484)
were more likely than suicide attempters (n ¼2819) to report religious denomination
in Estonia (OR¼0.5) and subjective religiosity in four countries: Brazil
(OR¼0.2), Estonia (OR¼0.5), Islamic Republic of Iran (OR¼0.6), and
Sri Lanka (OR¼0.4). In South Africa, the effect was exceptional both for religious
denomination (OR¼5.9) and subjective religiosity (OR¼2.7). No effects were
found 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), research
findings on the impact of religiosity on
suicidal behaviors has tended to favor the
idea of inverse association and protective
effect. Although exceptional and contro-
versial findings on this issue cannot be
denied, a higher level of religiosity indicates
a lower level of suicidality.
Due to conceptual and methodological
discrepancies, most of the studies per-
formed so far are hardly comparable. The
majority of studies have been ecological
by design and relatively few individual-level
findings have been reported. Furthermore,
while the majority of studies have been
conducted in developed countries and
based predominantly on US data, less work
has been done in developing countries,
within the Eastern cultural system or in
more secularized societies (Colucci &
Martin, 2008; Stack & Kposowa, 2008;
Vijayakumar, John, Pirkis et al., 2005).
Koenig and colleagues (2001) have
defined religion as an organized system of
beliefs, practices, rituals, and symbols
designed to facilitate closeness to the
sacred or transcendent. However, religion
is a wide concept that is comprised of
different dimensions. The present study
focuses on three dimensions of religion:
religious denomination, organizational
religiosity, and subjective religiosity.
Archives of Suicide Research, 14:44–55, 2010
Copyright # International Academy for Suicide Research
ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811110903479052
44
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
98
Durkheim illustrated the protective
effect provided by religious denomi-
nation via social integration and regu-
lation with the lower suicide rates
reported in Catholic countries compared
with Protestant countries (Durkheim,
1897=2002). A comparison between
Islam and Christianity has shown that
the strong degree of integration between
individual and society developed by
followers of the Islamic tradition has a
reducing effect on suicide rate (Bertolote
& Fleischmann, 2002; Simpson &
Conklin, 1988). Although several studies
have supported Durkheim’s classical
findings (Dervic, Oquendo, Grunebaum
et al., 2004; Faria, Victora, Meneghel
et al., 2006), others doubt the effect of
religious denomination as a measure of
religious integration and regulation in
the contemporary world (Moreira-
Almeida, Neto, & Koenig, 2006; Neeleman,
de Graaf, & Vollebergh, 2004), partially
due to the growing convergence of
Catholicism and Protestantism (Stack,
1983). Regardless of type, religion in
general may provide protection from
suicide (Breault, 1986) and the presence
or absence of religious denomination
may be more useful than the evaluation
of an association between specific religious
denominations and suicidal behaviors
(Dervic, Oquendo, Grunebaum et al.,
2004; Faria, Victora, Meneghel et al.,
2006).
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,
Chambers, Corcoran 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 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 closely
inversely 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 be
discerned. Pescosolido and Georgianna
(1989) claimed that either religious or other
network ties have both integrative and
regulative aspects and act therefore as
important sources of social and emotional
support. Another study showed that
visiting or talking with friends or relatives
did not reduce the likelihood of suicide,
but frequent participation in religious
activities did, which suggests that some-
thing more specifically intrinsic in religious
identity might be responsible for decreasing
suicide risk (Nisbet, Duberstein, Conwell
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,
Neto, & Koenig, 2006). In postmodern
societies, personal beliefs are at least as
relevant as integration in religious institu-
tions when explaining individual and group
behaviors (Neeleman, 1998; Stack, 1983).
The dimension of subjective religiosity
leads us closer to the concept of spiritu-
ality, which has been described as less
formal 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 the
postmodern era (Hay, 2002).
The aim of the current study was to
investigate whether religiosity assessed in
these dimensions—religious denomination,
organizational religiosity, and subjective
religiosity—could serve as a protective
factor against attempted suicide from a
cross-cultural perspective.
M. Sisask et al.
ARCHIVES OF SUICIDE RESEARCH 45
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
99
METHOD
General Description
In 2000, the World Health Organization
(WHO) launched the worldwide intervention
study on suicidal behavior SUPRE-MISS
(Suicide Prevention—Multisite Intervention
Study on Suicidal Behaviors) with the main
objective being to reduce the mortality
and morbidity associated with suicidal
behaviors. The methodology of SUPRE-
MISS was elaborated by a WHO expert
group and adapted to the local conditions
of each participating site (WHO, 2002).
The study was conducted in seven
culturally diverse low- and middle-income
countries around the world: Brazil
(Campinas), Estonia (Tallinn), India
(Chennai), Islamic Republic of Iran (Karaj),
South Africa (Durban), Sri Lanka
(Colombo), Vietnam (Hanoi). The research
protocol was approved by the relevant
ethics committee in each site. The detailed
description of the study and the character-
istics of the suicide attempters as well as the
community survey have been previously
presented 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 staff
identified suicide attempters in one or
more emergency settings within a catch-
ment area that had a population of at
least 250,000. Once medically stable,
the suicide attempters were asked to fill
in a consent form and were thereafter
interviewed by clinically experienced
and specially trained psychiatrists, medi-
cal doctors, psychologists or psychiatric
nurses.
In the same catchment areas, at
least 500 randomly selected community
members from the general population
were interviewed for the community
survey. These community members also
served as controls for the suicide
attempters. All participants provided
informed consent. The interviewers
were specially trained nurses, psycholo-
gists, medical students, medical doctors,
family health workers, and public health
professionals.
In total, 2819 suicide attempters and
5484 controls were interviewed. Detailed
numbers 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
Ã
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.
Ã
Suicidal–persons reporting suicidal behavior (attempts, plans, thoughts) during their
lifetime.
Religiosity Against Attempted Suicide
46 VOLUME 14 NUMBER 1 2010
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
100
Instruments
The questionnaire for suicide attemp-
ters, based on the European parasuicide
study interview schedule (EPSIS) of the
WHO=EURO multicenter study on
suicidal behavior, and a common survey
instrument for the community survey were
developed, translated and pilot-tested in
each site (Kerkhof, Bernasco, Bille-Brahe
et al., 1999; WHO, 2002).
Both the suicide attempters and
controls 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 (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.
To assess suicidal behavior during
their life-time, the controls were asked the
following questions:
1. Have you ever seriously thought about
committing 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 these
questions, a control was classified as suici-
dal and excluded from logistic regression
analysis as improper for the control group
(Table 1).
A recurring problem in sociological
work is the confounding effect of several
characteristics, which may act as buffers,
provide protection against attempted
suicide and adjust thereby the effect of
religiosity less significant (Stack, 2000). In
the current study, the following socio-
demographic control variables were avail-
able within the SUPRE-MISS instruments.
These included in the regression analysis
to statistically control them:
1. Age in years
2. Gender: males and females
3. Marital status: living with partner
(recoded from: married or living with
permanent partner) and living without
partner (recoded from: single; widowed;
divorced= separated)
4. Employment status: economically active
(recoded from: full-time employed;
part-time employed; employed, but on
sick leave; temporary work) and
economically inactive (recoded from:
unemployed; armed service; full-time
student; disabled, permanently sick;
retired; housewife=homemaker)
5. Educational status: high educational
status (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 with
the SPSS program (version 14.0). Differ-
ences between suicide attempters and the
control group were evaluated by chi-square
tests. For logistic regression analysis, the
religious denomination was recoded to
‘‘no’’ and ‘‘yes’’ (for any denomination)
answers; frequency of going to church
was recoded to ‘‘never’’; ‘‘weekly’’;
‘‘monthly’’; and ‘‘yearly’’; and for subjective
religiosity, the original values ‘‘no’’ and
‘‘yes’’ were used. Binary and multinomial
logistic regression analyses were performed
to calculate odds ratios (OR) with a
95% confidence interval (95% CI). Socio-
demographic variables (age, gender, marriage,
M. Sisask et al.
ARCHIVES OF SUICIDE RESEARCH 47
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
101
T
A
B
L
E
2
.
R
e
l
i
g
i
o
u
s
D
e
n
o
m
i
n
a
t
i
o
n
:
S
u
i
c
i
d
e
A
t
t
e
m
p
t
e
r
s
(
S
A
)
i
n
C
o
m
p
a
r
i
s
o
n
w
i
t
h
C
o
n
t
r
o
l
G
r
o
u
p
(
C
G
)
N
o
n
e
P
r
o
t
e
s
t
a
n
t
i
s
m
C
a
t
h
o
l
i
c
i
s
m
J
e
w
i
s
h
I
s
l
a
m
H
i
n
d
u
i
s
m
O
r
t
h
o
d
o
x
B
u
d
d
h
i
s
m
O
t
h
e
r
T
o
t
a
l
B
r
a
z
i
l
C
G
N
4
2
1
0
0
3
4
4
0
0
0
0
2
2
8
5
1
6
%
8
.
1
1
9
.
4
6
6
.
7
0
0
0
0
0
.
4
5
.
4
1
0
0
S
A
N
2
3
4
7
7
5
0
0
1
0
0
8
1
5
4
%
1
4
.
9
3
0
.
5
4
8
.
7
0
0
0
.
6
0
0
5
.
2
1
0
0
E
s
t
o
n
i
a
C
G
N
2
4
3
5
8
2
1
3
2
0
1
2
7
1
4
3
4
9
8
%
4
8
.
8
1
1
.
6
4
.
2
0
.
6
0
.
4
0
2
5
.
5
0
.
2
8
.
6
1
0
0
S
A
N
2
2
3
3
3
6
0
0
0
6
5
1
4
3
3
2
%
6
7
.
2
9
.
9
1
.
8
0
0
0
1
9
.
6
0
.
3
1
.
2
1
0
0
I
n
d
i
a
C
G
N
0
0
1
6
0
2
3
4
6
0
0
0
1
5
0
0
%
0
0
3
.
2
0
4
.
6
9
2
.
0
0
0
0
.
2
1
0
0
S
A
N
1
2
4
4
4
0
2
5
5
7
1
0
1
1
4
6
8
0
%
0
.
1
3
.
5
6
.
5
0
3
.
7
8
4
.
0
0
0
.
1
2
.
1
1
0
0
I
s
l
a
m
i
c
R
e
p
u
b
l
i
c
o
f
I
r
a
n
C
G
N
0
0
0
0
5
0
2
0
0
0
2
5
0
4
%
0
0
0
0
9
9
.
6
0
0
0
0
.
4
1
0
0
S
A
N
0
0
0
0
6
3
2
0
0
0
0
6
3
2
%
0
0
0
0
1
0
0
0
0
0
0
1
0
0
S
o
u
t
h
A
f
r
i
c
a
C
G
N
8
3
8
1
6
8
1
1
3
6
2
1
0
1
8
8
4
9
7
%
1
6
.
7
1
6
.
3
1
3
.
7
0
.
2
2
.
6
1
2
.
5
0
.
2
0
3
7
.
8
1
0
0
S
A
N
2
4
3
1
7
4
0
2
8
1
1
4
0
1
2
9
3
5
6
5
%
4
.
2
5
.
5
1
3
.
1
0
5
.
0
2
0
.
2
0
0
.
2
5
1
.
9
1
0
0
S
r
i
L
a
n
k
a
C
G
N
1
3
8
4
0
1
6
1
1
1
6
0
2
9
1
7
6
6
3
%
0
.
2
0
.
5
1
2
.
7
0
2
4
.
3
1
7
.
5
0
4
3
.
9
1
.
1
1
0
0
S
A
N
0
2
5
4
1
3
8
3
1
0
1
7
1
3
3
0
0
%
0
0
.
7
1
8
.
0
0
.
3
1
2
.
7
1
0
.
3
0
5
7
.
0
1
1
0
0
V
i
e
t
n
a
m
C
G
N
2
0
7
4
1
6
4
0
1
3
2
0
2
1
2
8
2
2
2
7
7
%
9
1
.
1
0
.
7
1
.
8
0
.
6
0
.
1
0
0
.
1
5
.
6
0
.
1
1
0
0
S
A
N
1
3
4
0
1
0
0
0
0
9
0
1
4
4
%
9
3
.
1
0
0
.
7
0
0
0
0
6
.
3
0
1
0
0
48 VOLUME 14 NUMBER 1 2010
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
102
employment, education) were included in
the regression analysis to statistically
control them. The level of statistical signifi-
cance was set at a ¼0.05.
RESULTS
Religious Denomination
The results of the study revealed a large
diversity of religious denominations across
participating sites. Predominant religions
were Catholicism and Protestantism in
Brazil; Protestantism and Orthodox, in
addition to a great amount of people with-
out religious denomination, in Estonia;
Hinduism in India; Islam (Shi’ite) in the
Islamic Republic of Iran; various denomi-
nations without any of them prevailing in
South Africa; and Buddhism in Sri Lanka.
In Vietnam, most of the people reported
no religious denomination (Table 2). Dif-
ferences between suicide attempters and
the 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 Islamic
Republic of Iran (p ¼0.197), where in both
groups the main religious denomination
was Islam, and in Vietnam (p ¼0.859),
where in both groups the majority of
people had no religious denomination.
In total, males and females tended to
have similar patterns of distribution with
two exceptions only—there were no sig-
nificant differences between the suicide
attempters and the control groups among
females in India (p ¼0.067) and among
males in Brazil (p ¼0.852).
Effect of Religious Denomination,
Organizational Religiosity, and Subjective
Religiosity
In India, Sri Lanka and the Islamic
Republic of Iran all controls and=or suicide
attempters had some kind of religious
denomination, therefore the odds ratio
was not calculable. Religious denomination
was more likely to be reported by the con-
trols than the suicide attempters in Estonia
and less likely to be reported in South
Africa. In Brazil and Vietnam, the effect
of religious denomination was statistically
non-significant (Table 3).
The frequency of attending church or
another place of worship (organizational
religiosity) demonstrated a distinctly
protective effect in Brazil and Iran; yet in
South Africa and Sri Lanka, the odds ratios
were statistically non-significant. In
Estonia, only monthly visits served as a
protective factor while weekly and yearly
visits were statistically non-significant.
However, in India and Vietnam yearly
visits had a protective effect and weekly
or monthly visits remained statistically non-
significant. Controversial results came from
Vietnam as weekly visits were statistically
non-significant, monthly visits demon-
strated risk effect and yearly visits a protec-
tive effect (Table 4).
TABLE 3. Religious Denomination

: Suicide
Attempters in Comparison with
Control Group, Binary Logistic
Regression Analysis Adjusted
for 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) versus
none.
M. Sisask et al.
ARCHIVES OF SUICIDE RESEARCH 49
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
103
In Brazil, Estonia, the Islamic Republic
of Iran and Sri Lanka, controls were more
likely to consider themselves to be religious
(subjective religiosity) compared with
suicide attempters; in South Africa, con-
trols were less likely to consider themselves
religious. In India and Vietnam, the odds
ratio of subjective religiosity was statisti-
cally non-significant (Table 5).
DISCUSSION
The aim of this study was to find out
whether different dimensions of religiosity—
religious denomination, organizational religi-
osity, and subjective religiosity—could serve
as possible protective factors against attempted
suicide.
Suicidal behaviors are a global public
health problem and a complex phenom-
enon influenced by a number of mixed
biological, psychological, social and cultural
factors. Among other agents, religious con-
text has been recognized as a major cultural
factor in the determination of suicidal
behaviors (Bertolote & Fleischmann, 2002;
Stack, 2000). To the best of our knowledge,
the present study is the first individual-level
TABLE 5. Subjective Religiosity
Ã
, Suicide
Attempters in Comparison with
Control Group, Binary Logistic
Regression Analysis Adjusted
for Gender, Age, Marriage,
Employment and Education
95% CI
OR Lower Higher p-value
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.
Ã
Subjective religiosity – considering him=her-
self as religious person.
TABLE 4. Organizational Religiosity
Ã
, Suicide
Attempters in Comparison with
Control Group, Multinominal
Logistic Regression Analysis
ÃÃ
adjusted for Gender, Age, Marriage,
Employment and Education
95% CI
OR Lower Higher p-value
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.
Ã
Organizational religiosity – frequency of going
to church or other place of worship.
ÃÃ
Reference category—never.
Religiosity Against Attempted Suicide
50 VOLUME 14 NUMBER 1 2010
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
104
study conducted concurrently in culturally
different sites, which enables the effect of
religiosity on suicide attempts to be investi-
gated from a cross-cultural perspective.
However, the results of the study cannot
be interpreted without keeping in mind
the reliability of self-reported information
about sensitive issues, the complexity of
suicidal behaviors and the knowledge that
religiosity is not the only, all-powerful
factor associated with suicidality. Moreover,
both religion and suicidal behaviors are
social constructs and consequently dynamic
across eras and cultures.
In most known religions of the world,
suicide is condemned; especially in the
three monotheistic religions of Judaism,
Christianity and Islam. However, the
strength of this condemnation has varied
over time and within the religions them-
selves. Within Christianity, the conservative
church members (Catholic and Orthodox)
have been the most outspoken against
suicide with the sixth commandment
(‘‘Thou shall not kill’’) used as the official
Christian statement prohibiting suicide
(Kelleher, Chambers, Corcoran et al.,
1998; Pescosolido & Georgianna, 1989).
Both Hindus and Buddhists are more
ambivalent in their attitudes towards suici-
dal behaviors. 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 handi-
cap (Tousignant, Seshadri, & Raj, 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 to heaven. Sui-
cide is considered a sin and subsequently a
crime, but it is also a shameful act within
the family and subsequently must be con-
cealed (Khan & Reza, 2000). Still, the Islam
religion condemns on one hand and
forgives on the other, as suicide victims
are often seen as mentally ill (Simpson &
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 terrorist population
(Townsend, 2007).
The prevailing religious denominations
across the SUPRE-MISS sites differed to a
large extent and most of the major religions
in the world were represented. The sites
differed substantially across the religiosity-
secularity spectrum. Some sites were very
religious (India, the Islamic Republic of
Iran, Sri Lanka) and some were very or
rather secular (Vietnam, Estonia). Brazil
and South Africa were more ambivalent
in their religiosity. In India, the Islamic
Republic of Iran and Sri Lanka, the effect
of religious denomination on suicide
attempts was not calculable, as both con-
trols and suicide attempters reported some
kind of religious denomination. In a very
secular country, such as Vietnam, religious
denomination had no effect against
attempted suicide. A protective effect
emerged only in Estonia which is rather
secular but still a predominantly Christian
country.
In Brazil, the other Christian country,
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 Brazil but it can be assumed
that Protestantism could neutralize the pro-
tective effect of Catholicism. However, this
is only a speculation. This study analyzed
Christianity as a whole as differentiating
the 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 lifetime
prevalence of suicidal ideation among Pro-
testants was lower than among Catholics.
M. Sisask et al.
ARCHIVES OF SUICIDE RESEARCH 51
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
105
South Africa, the most pluralistic
country, was the only site where religious
denomination showed a risk effect. South
Africa has been described as ‘‘The Rainbow
Nation’’ because of its cultural diversity.
There are a variety of ethnic groups and a
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 cul-
tural group levels (Wassenaar, van der Veen,
& Pillay, 1998). Subsequently, there is a large
diversity of religious denominations and this
does not seem favorable in terms of provid-
ing protection against attempted suicide.
There is a study available which demon-
strates that religious homogeneity, which
increases social interaction and social bonds
between individuals with shared cultural
values, is inversely associated with suicide
rate (Ellison, Burr, & McCall, 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 intra-
personal or psychological perspectives
(Flannelly, Ellison, & Strock, 2004).
The frequency of attending church
or other place of worship in different
SUPRE-MISS sites gave controversial
results. In the predominantly Christian
Brazil and the Islamic Republic of Iran,
the frequency of church attendance pro-
vided an unequivocal protective effect
against attempted suicide. No effect of
organizational religiosity on suicide
attempts was detected in Sri Lanka and
South Africa, the two most heterogeneous
sites of religious denomination. Somewhat
confusing results on organizational religi-
osity came from Estonia, India and Viet-
nam. To interpret these results, the
meaning of going to church and, even
more specifically, the meaning of the fre-
quency of church attendance within differ-
ent cultures needs further explanation.
Subjective religiosity is very informal
and a deeply subjective psychological con-
struct. It may mediate health outcomes
through engendering feelings of self-esteem,
self-worth and positive emotions thus pro-
viding a sense of meaning, fostering feelings
of 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 of
religiosity. The controls within the SUPRE-
MISS study were more likely to report sub-
jective religiosity than suicide attempters in
four sites out of seven (Brazil, Estonia, the
Islamic Republic of Iran and Sri Lanka). In
two sites (India and Vietnam), the effect
was statistically non-significant. It is known
from previous research that, in India, sub-
jective religiosity protects against completed
suicide, not against attempted suicide
(Vijayakumar, 2003). The results from Viet-
nam can be attributed to its secularity, which
may influence the overall way of thinking
and mentality. In South Africa, the risk
effect of subjective religiosity was an excep-
tional result again, as was also true for the
effect of religious denomination. As men-
tioned above, this can be explained by the
cultural diversity, heterogeneity and blurring
of cultural norms within the site.
In conclusion, according to the results
of the current study, individual-level asso-
ciations between different dimensions of
religiosity and attempting suicide exist.
Nevertheless, these associations varied
between dimensions of religiosity and
across cultures. In particular, subjective
religiosity (considering him=herself to be
a religious person) may serve as a protec-
tive factor against non-fatal suicidal
behaviors in some cultures.
Limitations
The SUPRE-MISS study was not
specifically designed to study the effects
Religiosity Against Attempted Suicide
52 VOLUME 14 NUMBER 1 2010
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
106
of religion on suicidal behaviors, therefore
no specifically designed scales were
included in the questionnaire. The infor-
mation regarding religiosity 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 could be incomplete due to
respondents’ memory bias and unwilling-
ness to report honestly on sensitive issues
like religiosity. Measuring religion with a
single question is a general limitation of
studies in which religion is a minor or inci-
dental variable, rather than the primary
focus (Flannelly, Ellison, & Strock, 2004).
Another limitation is that religiosity
has other aspects which 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. Moreover, religiosity is
not the only factor which has an effect on
attempted suicide. In the current study, the
effect of the main socio-demographic vari-
ables (age, gender, marriage, employment,
education) was statistically controlled and,
even with other confounders, the indirect
effects of religion are important. It can help
to understand what factors influence health
behaviors, social support and this knowledge
can have valuable intellectual and practical
implications, for example influencing public
health (Flannelly, Ellison, & Strock, 2004).
AUTHOR NOTE
This paper is based on the data and
experience obtained during the authors’
participation in the WHO Multisite
Intervention Study on Suicidal Behaviors
(SUPRE-MISS), a project funded by the
World Health Organization and the partici-
pating field research centers.
The collaborating investigators in this
study have been (in alphabetical order):
Dr. Damani De Silva, Colombo; Prof. Van
Tuong Nguyen, Hanoi; Prof. Lourens
Schlebusch, Durban; Prof. Diego De Leo,
Brisbane has acted as scientific advisor
for the WHO SUPRE-MISS study.
The Tallinn center obtained additional
funding from the following agencies: the
Estonian Health Insurance Fund; National
Prevention of Suicide and Mental
Ill-Health (NASP) at Karolinska Institute
and Stockholm County Council’s Centre
for Suicide Research and Prevention; the
Estonian Scientific Foundation (Project
No. 7132).
Thanks are due to Maimu No˜mmik
and Kathy McKay for their thorough
linguistic and stylistic revision of the
manuscript.
Merike Sisask, Estonian-Swedish Men-
tal Health and Suicidology Institute (ERSI)
and Tallinn University, Tallinn, Estonia.
Airi Va¨rnik, Estonian-Swedish Mental
Health and Suicidology Institute (ERSI)
and Tallinn University, Tallinn, Estonia,
and National Prevention of Suicide and
Mental Ill-Health (NASP) at Karolinska
Institute and Stockholm County Council’s
Centre for Suicide Research and Preven-
tion; WHO Lead Collaborating Centre of
Mental Health Problems and Suicide
Across Europe, Stockholm, Sweden.
Kairi Ko˜lves, Estonian-Swedish Men-
tal Health and Suicidology Institute (ERSI),
Tallinn, Estonia and Australian Institute
for Suicide Research and Prevention
(AISRAP), Brisbane, Australia.
Jose´ M. Bertolote, Department of
Mental Health and Substance Abuse,
World Health Organization, Geneva,
Switzerland. The author is staff member
of the World Health Organization. The
author alone is responsible for the views
expressed in this publication and they do
not necessarily represent the decisions,
policy or views of the World Health
Organization.
Jafar Bolhari, Tehran Psychiatric
Institute (IUMS), Mental Health Research
Center, Tehran, Islamic Republic of Iran.
M. Sisask et al.
ARCHIVES OF SUICIDE RESEARCH 53
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
107
Neury J. Botega, Department of
Psychiatry, FCM – UNICAMP, Campinas,
Brazil.
Alexandra Fleischmann, Department of
Mental Health and Substance Abuse, World
Health Organization, Geneva, Switzerland.
The author is staff member of the World
Health Organization. The author alone is
responsible for the views expressed in this
publication and they do not necessarily rep-
resent the decisions, policy or views of the
World Health Organization.
Lakshmi Vijayakumar, Department of
Psychiatry, 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 Suicide
Research and Prevention; WHO Lead
Collaborating Centre of Mental Health
Problems and Suicide Across Europe,
Stockholm, Sweden.
Correspondence concerning this article
should be addressed to Merike Sisask,
Estonian-Swedish Mental Health and
Suicidology Institute (ERSI), O
˜
ie 39,
Tallinn 11615 Estonia. E-mail: merike.
sisask@neti.ee
REFERENCES
Bertolote, J. M., & Fleischmann, A. (2002). A global
perspective in the epidemiology of suicide.
Suicidologi, 7(2), 6–7.
Bertolote, J. M., Fleischmann, A., De Leo, D., et al.
(2005). Suicide attempts, plans, and ideation in
culturally diverse sites: The WHO SUPRE-MISS
community survey. Psychological Medicine, 35(10),
1457–1465.
Bolz, W. (2002). Psychological analysis of the Sri
Lankan conflict culture with special reference to
the high suicide rate. Crisis, 23(4), 167–170.
Botega, N. J., de Azevedo Barros, M. B., de Oliveira,
H. B., et al. (2005). Suicidal behavior in the
community: Prevalence and factors associated
with suicidal ideation. Revista Brasileira de Psiquia-
tria, 27(1), 45–53.
Breault, K. D. (1986). Suicide in America: A test of
Durkheim’s theory of religious and family integration,
1933–1980. The American Journal of Sociology, 92(3),
628–656.
Colucci, E., & Martin, G. (2008). Religion and
spirituality along the suicidal path. Suicide &
Life-Threatening Behavior, 38(2), 229–244.
da Silva, V. F., de Oliveira, H. B., Botega, N. J., et al.
(2006). Factors associated with suicidal ideation in
the community: A case-control study. Cadernos de
Sau´de Pu´blica, 22(9), 1835–1843.
Dervic, K., Oquendo, M. A., Grunebaum, M. F., et al.
(2004). Religious affiliation and suicide attempt. The
American Journal of Psychiatry, 161(12), 2303–2308.
Duberstein, P. R., Conwell, Y., Conner, K. R., et al.
(2004). Poor social integration and suicide: Fact or
artifact? A case-control study. Psychological Medicine,
34(7), 1331–1337.
Durkheim, E
´
. (1897=2002). Suicide: A study in sociology.
London and New York: Routledge Classics.
Ellison, C. G., Burr, J. A., & McCall, P. L. (1997).
Religious homogeneity and metropolitan suicide
rates. Social Forces, 76(1), 273–299.
Faria, N. M., Victora, C. G., Meneghel, S. N., et al.
(2006). Suicide rates in the State of Rio Grande
do Sul, Brazil: Association with socioeconomic,
cultural, and agricultural factors. Cadernos de Sau´de
Pu´blica, 22(12), 2611–2621.
Flannelly, K. J., Ellison, C. G., & Strock, A. L. (2004).
Methodologic issues in research on religion and
health. The Southern Medical Journal, 97(12), 1231–1241.
Fleischmann, A., Bertolote, J. M., De Leo, D., et al.
(2005). Characteristics of attempted suicides seen
in emergency-care settings of general hospitals in
eight low- and middle-income countries. Psychologi-
cal Medicine, 35(10), 1467–1474.
Hay, D. (2002). The spirituality of adults in Britain—
recent research. Scottish Journal of Healthcare
Chaplaincy, 5(1), 4–10.
Kelleher, M. J., Chambers, D., Corcoran, P., et al
(1998). Religious sanctions and rates of suicide
worldwide. Crisis, 19(2), 78–86.
Kerkhof, A. J. F. M., Bernasco, W., Bille-Brahe, U.,
et al. (1999). European parasuicide study interview
schedule (EPSIS). In U. Bille-Brahe (Ed.), Facts
and Figures: WHO=EURO. Copenhagen: WHO
Regional Office for Europe.
Khan, M. M., & Reza, H. (2000). The pattern of
suicide in Pakistan. Crisis, 21(1), 31–35.
Koenig, H. G. (2005). Faith and mental health: Religious
resources for healing. West Conshohocken: Temple-
ton Foundation Press.
Religiosity Against Attempted Suicide
54 VOLUME 14 NUMBER 1 2010
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
108
Koenig, H. G., McCullough, M. E., & Larson, D. B.
(2001). Handbook of religion and health. New York:
Oxford University Press.
Lester, D. (2006). Suicide and Islam. Archives of Suicide
Research, 10(1), 77–97.
Moreira-Almeida, A., Neto, F. L., & Koenig, H. G.
(2006). Religiousness and mental health: A review.
Revista Brasileira de Psiquiatria, 28(3), 242–250.
Musick, M. A., House, J. S., & Williams, D. R. (2004).
Attendance at religious services and mortality in a
national sample. Journal of Health and Social Behavior,
45(2), 198–213.
Neeleman, J. (1998). Regional suicide rates in the
Netherlands: Does religion still play a role? Inter-
national Journal of Epidemiology, 27(3), 466–472.
Neeleman, J., de Graaf, R., & Vollebergh, W. (2004).
The suicidal process; prospective comparison
between early and later stages. Journal of Affective
Disorders, 82(1), 43–52.
Nisbet, P. A., Duberstein, P. R., Conwell, Y., et al.
(2000). The effect of participation in religious
activities on suicide versus natural death in adults
50 and older. The Journal of Nervous and Mental
Disease, 188(8), 543–546.
Pescosolido, B. A., & Georgianna, S. (1989).
Durkheim, suicide, and religion: Toward a network
theory of suicide. American Sociological Review, 54(1),
33–48.
Siegrist, M. (1996). Church attendance, denomi-
nation, and suicide ideology. The Journal of Social
Psychology, 136(5), 559–566.
Simpson, M. E., & Conklin, G. H. (1988). Socioeco-
nomic development, suicide and religion: A test of
Durkheim’s theory of religion and suicide. Social
Forces, 67(4), 945–964.
Stack, S. (1983). The effect of religious commitment
on suicide: A cross-national analysis. Journal of
Health and Social Behavior, 24(4), 362–374.
Stack, S. (2000). Suicide: A 15-year review of the
sociological literature. Part II: Modernization
and social integration perspectives. Suicide &
Life-Threatening Behavior, 30(2), 163–176.
Stack, S., & Kposowa, A. J. (2008). The association
of suicide rates with individual-level suicide
attitudes: A cross-national analysis. Social Science
Quarterly, 89(1), 39–59.
Stack, S., & Lester, D. (1991). The effect of religion
on suicide ideation. Social Psychiatry and Psychiatric
Epidemiology, 26(4), 168–170.
Tousignant, M., Seshadri, S., & Raj, A. (1998).
Gender and suicide in India: A multiperspective
approach. Suicide & Life-Threatening Behavior,
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.
ARCHIVES OF SUICIDE RESEARCH 55
D
o
w
n
l
o
a
d
e
d

B
y
:

[
T
a
r
t
u

U
n
i
v
e
r
s
i
t
y

L
i
b
r
a
r
y
]

A
t
:

1
2
:
5
3

1

F
e
b
r
u
a
r
y

2
0
1
0
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
WHO/MSD/MBD/02.1
Page 6
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
WHO/MSD/MBD/02.1
Page 8
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
WHO/MSD/MBD/02.1
Page 9
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
WHO/MSD/MBD/02.1
Page 10
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
WHO/MSD/MBD/02.1
Page 11
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
WHO/MSD/MBD/02.1
Page 12
INSTRUCTIONS FOR THE INTERVIEWER
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. SOCIO-DEMOGRAPHIC INFORMATION
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
WHO/MSD/MBD/02.1
Page 13
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 _ 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 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
������
1 2 888 999
_ _ Weeks
1 2 3 4 5 6 7
8 9 10 11
888 999
119
WHO/MSD/MBD/02.1
Page 14
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
INSTRUCTIONS FOR THE INTERVIEWER
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.”
Rate “888” if information is not available and “999” if item is not applicable.
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
WHO/MSD/MBD/02.1
Page 15
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
WHO/MSD/MBD/02.1
Page 16
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
WHO/MSD/MBD/02.1
Page 17
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 _ _ _ _ _ _ _ _ _
6.4.2b “Model number 2: method (please fill in corresponding code, see 3.5) _ _ _ _ _ _
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 _ parent
2 _ child
3 _ sister or brother
4 _ spouse
5 _ boy-/girlfriend
6 _ friend
7 _ other, specify _ _ _ _ _ _ _ _ _
6.4.3b “Model number 3: method (please fill in corresponding code, see 3.5) _ _ _ _ _ _
6.4.3c “Model” number 3: 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
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
WHO/MSD/MBD/02.1
Page 18
6.4.4a “Model” number 4: who?
1 _ parent
2 _ child
3 _ sister or brother
4 _ spouse
5 _ boy-/girlfriend
6 _ friend
7 _ other, specify _ _ _ _ _ _ _ _ _
6.4.4b “Model number 4: method (please fill in corresponding code, see 3.5) _ _ _ _ _ _
6.4.4c “Model” number 4: 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
6.4.5a “Model” number 5: who?
1 _ parent
2 _ child
3 _ sister or brother
4 _ spouse
5 _ boy-/girlfriend
6 _ friend
7 _ other, specify _ _ _ _ _ _ _ _ _
6.4.5b “Model number 5: method (please fill in corresponding code, see 3.5) _ _ _ _ _ _
6.4.5c “Model” number 5: 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
6.5 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
WHO/MSD/MBD/02.1
Page 19
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:
6.7.2.1 Parent 1_No 2_Yes
6.7.2.2 Brother or sister 1_No 2_Yes
6.7.2.3 Child 1_No 2_Yes
6.7.2.4 Grandparent 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 2 888 999
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
WHO/MSD/MBD/02.1
Page 20
INSTRUCTIONS FOR THE INTERVIEWER
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
INSTRUCTIONS FOR THE INTERVIEWER
Please ask the interviewee the following questions and give the following introduction:
“In the following, I will ask general questions about your health.”
Rate “888” if information is not available and “999” if item is not applicable.
7. PHYSICAL HEALTH, CONTACT WITH HEALTH SERVICES,
MENTAL 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
WHO/MSD/MBD/02.1
Page 21
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
WHO/MSD/MBD/02.1
Page 22
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
WHO/MSD/MBD/02.1
Page 23
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? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7.14.2 How long have you had this? 555 _ from birth on
_ _ (Years)
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
WHO/MSD/MBD/02.1
Page 24
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
WHO/MSD/MBD/02.1
Page 25
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
WHO/MSD/MBD/02.1
Page 26
INSTRUCTIONS FOR THE INTERVIEWER
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. ALCOHOL AND DRUG RELATED QUESTIONS
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.)?
1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily
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
WHO/MSD/MBD/02.1
Page 27
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
WHO/MSD/MBD/02.1
Page 28
INSTRUCTIONS FOR THE INTERVIEWER
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”.
Rate “888” if information is not available and “999” if item is not
applicable.
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
WHO/MSD/MBD/02.1
Page 29
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
WHO/MSD/MBD/02.1
Page 30
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
WHO/MSD/MBD/02.1
Page 31
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
WHO/MSD/MBD/02.1
Page 32
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
WHO/MSD/MBD/02.1
Page 33
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
WHO/MSD/MBD/02.1
Page 34
INSTRUCTIONS FOR THE INTERVIEWER
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.”
Rate “888” if information is not available and “999” if item is not applicable.
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
WHO/MSD/MBD/02.1
Page 35
INSTRUCTIONS FOR THE INTERVIEWER
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.”
Rate “888” if information is not available and “999” if item is not applicable.
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
WHO/MSD/MBD/02.1
Page 36
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
WHO/MSD/MBD/02.1
Page 37
Annex 2
SUPRE-MISS COMMUNITY SURVEY
INSTRUCTIONS FOR THE INTERVIEWER
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
WHO/MSD/MBD/02.1
Page 38
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. SOCIO-DEMOGRAPHIC INFORMATION
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
WHO/MSD/MBD/02.1
Page 39
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 _ 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 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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
WHO/MSD/MBD/02.1
Page 40
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
WHO/MSD/MBD/02.1
Page 41
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
If answer is no, skip sub-questions and go to question 2.3.
2.2.1 How old were you the first time this happened? _ _ years old
2.2.2 Did this happen to you at all in the last twelve months? 1_ No 2_ Yes
2.2.3 How old were you the last time this happened to you? _ _ years old
2.3 Have you ever attempted suicide? 1_ No 2_ Yes
If answer is no, skip sub-questions and go to question 2.4.
2.3.1 How many times ever in your lifetime have you attempted suicide?
(Number of times) _ _
2.3.2 How old were you the first time this happened? _ _ years old
2.3.3 How old were you the last time this happened to you? _ _ years old
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
WHO/MSD/MBD/02.1
Page 42
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:
2.4.1.1 Parent 1_No 2_Yes
2.4.1.2 Brother or sister 1_No 2_Yes
2.4.1.3 Child 1_No 2_Yes
2.4.1.4 Grandparent 1_No 2_Yes
2.4.2 Made a suicide attempt:
2.4.2.1 Parent 1_No 2_Yes
2.4.2.2 Brother or sister 1_No 2_Yes
2.4.2.3 Child 1_No 2_Yes
2.4.2.4 Grandparent 1_No 2_Yes
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
WHO/MSD/MBD/02.1
Page 43
3. PHYSICAL HEALTH, CONTACT WITH HEALTH SERVICES,
MENTAL HEALTH
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? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3.3.2 How long have you had this? 555 _ from birth on
_ _ (Years)
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
WHO/MSD/MBD/02.1
Page 44
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? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3.8.2 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
555 _ _ 888 999
150
WHO/MSD/MBD/02.1
Page 45
4. ALCOHOL AND DRUG RELATED QUESTIONS
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.)?
1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily
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.)?
1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily
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
WHO/MSD/MBD/02.1
Page 46
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
WHO/MSD/MBD/02.1
Page 49
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
WHO/MSD/MBD/02.1
Page 50
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
WHO/MSD/MBD/02.1
Page 51
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
WHO/MSD/MBD/02.1
Page 52
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 _ _ _ _ _ _ _ _ _ _
156
WHO/MSD/MBD/02.1
Page 53
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 _ _ _ _ _ _ _ _ _
157
WHO/MSD/MBD/02.1
Page 54
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 _ _ _ _ _ _ _ _ _ _
158
WHO/MSD/MBD/02.1
Page 55
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
WHO/MSD/MBD/02.1
Page 56
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 _ _ _ _ _ _ _ _ _ _
160
WHO/MSD/MBD/02.1
Page 57
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)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
161
WHO/MSD/MBD/02.1
Page 58
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”)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
162
WHO/MSD/MBD/02.1
Page 59
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. 13
th
ESSSB,
Rome, Italy, 2010
3. Laido Z, Yur’yev A, Sisask M, Värnik A. Definitions of suicide and non-fatal
suicidal acts. 13
th
ESSSB, Rome, Italy, 2010
4. Yur’yev A, Värnik A, Värnik P, Sisask M, Leppik L. Employment status and
suicide mortality in Europe. 13
th
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. 13
th
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
168
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
169
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


170
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)


171
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
172
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



173
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. 13
th
ESSSB,
Rome, Italy, 2010
3. Laido Z, Yur’yev A, Sisask M, Värnik A. Definitions of suicide and non-fatal
suicidal acts. 13
th
ESSSB, Rome, Italy, 2010
174
4. Yur’yev A, Värnik A, Värnik P, Sisask M, Leppik L. Employment status and
suicide mortality in Europe. 13
th
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. 13
th
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-
176
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
177
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
178
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.
179
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
180
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.

181
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.


Merike Sisask

The social construction and subjective meaning of attempted suicide

TALLINN 2010

Professor at the Chair of Psychophysiology of the Institute of Psychology of the Faculty of Social Sciences and Education of the University of Tartu Opponents The academic disputation on the dissertation will be held on January 14. MD PhD. 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. PDF) Tallinn University Narva mnt 25 10120 Tallinn www. LL. PDF) ISSN 1736-3675 (abstract. 2010 ISSN 1736-3632 (printed publication) ISBN 978-9949-463-61-9 (printed publication) ISSN 1736-793X (online. Tallinn. Tallinn University. 2011 at 10 o’clock. PDF) ISBN 978-9949-463-62-6 (online. Professor at the Institute of Social Work of Tallinn University. online. Dr. Professor at the Department of Sociology of Åbo Akademi University Ilkka Henrik Mäkinen. PhD. Professor at the Stockholm Centre on Health of Societies in Transition (SCOHOST) of the School of Social Sciences of Södertörn University Jaanus Harro. PDF): Tallinna Ülikool. Director of the Estonian-Swedish Mental Health and Suicidology Institute (ERSI) Mikko Kari Lagerspetz.ee . MD PhD. 2011. pol. Copyright: Merike Sisask.tlu. at Tallinn University lecture hall M-213. online. Supervisors Airi Värnik. Uus-Sadama 5. rer.M. PDF) ISBN 978-9949-463-63-3 (abstract.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. online. 2010 Copyright (abstract.

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

5

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

6

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 theoretical 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 construction 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 interaction, and prioritises the subjective meaning individuals attach to their behaviour. The aim of the current dissertation is to analyse attempted suicide as a social phenomenon, 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 perspective. The theoretical framework incorporates the articles under a single sociological umbrella and builds bridges between them. The first article shows how suicide attempters were identified in everyday interaction at emergency care departments of general hospitals and highlights the fact that accurate, standardised information 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 cultural 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 cultures. In particular, subjective religiosity may serve as a protective factor against non-fatal suicidal behaviours in some cultures. Structural and formal religious dimensions (religious denomination, organisational religiosity) seem to be less relevant. 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.

7

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

and Värnik. L. R. (2009).. and Wasserman. IV. (2005). J. Psychological Medicine. M. giving final approval to the manuscripts. (2010). A. M.. M. K.. Sisask. M. ERSI 10th anniversary collected papers. 62(6): 431-435. N. Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low. Värnik.). Fleischmann. J. Sisask. L.and middle-income countries. 9 . T. Kõlves.] Suitsiidiuuringud – Suicide Studies.. Severity of attempted suicide as measured by the Pierce Suicidal Intent Scale. Vijayakumar. giving final approval to the manuscript. Botega... D. Archives of Suicide Research. A. D.. Internet Comments on Media Reporting of Two Adolescents’ Collective Suicide Attempt. Konstabel. Schlebusch. (2005).. Värnik. Sisask. Botega. 83: 744-749. Värnik (Ed.. Tallinn: Iloprint: 65-69. Fleischmann. Sisask. Vjayakumar. and Kõlves. participating in writing the manuscript. A. [WHO-SUPRE – Worldwide suicide attempts study in Estonia. A. Wasserman.. Fleischmann.. II... V. De Leo.. and Wasserman. M. (2010).LIST OF PUBLICATIONS The following original publications are included in the current dissertation and will be referred to in the text of the dissertation by their respective number (in Roman numerals). Phillips.. J. carrying out and organising data collection. K. (2004). A. T. A.. M. Repetition of suicide attempts: data from five culturally different low. A. De Silva. M. Vjayakumar. J. Värnik. carrying out data analysis and interpretation. Sisask. Malakouti. Bolhari.. L.. K. D. D. ERSI 10. K... Is Religiosity a Protective Factor Against Attempted Suicide: A Cross-Cultural Case-Control Study. J. Nguyen. J. The author of the dissertation has contributed to these four publications as follows: (1) Article I: carrying out and organising data collection. (2008). aastapäeva kogumik. J. Bertolote. M. 30(3): 136-143. Sisask. (2) Articles II. M. (2003).. K. and Wasserman D. Schlebusch.. Botega. Archives of Suicide Research. Sisask. Additional articles of direct relevance Bertolote. M. and Wasserman D. K. Bertolote. WHO-SUPRE – Ülemaailmne suitsiidikatsete uuring Eestis. D. [Suicidality in society and the factors predicting suicide attempt. L. D. A. Bolhari. M... Värnik. Suitsidaalsus ühiskonnas ja suitsiidikatse sooritamist prognoosivad tegurid.] Eesti Arst. III and IV: formulating the research question.. writing manuscripts. Sisask. 1: 87-98. checking and validating data. Nguyen. A. I. Kõlves. De Leo. M.. creating research design. D. III. De Silva. Värnik. 35(10): 1467-1474.. D. M. Phillips.. Kõlves.. K. 14(1): 44-55. Nordic Journal of Psychiatry... N. Crisis.and middleincome country emergency care settings participating in the WHO SUPRE-MISS study.. and Wasserman. and Wasserman. L. N. V. Kõlves. 31(4): 194-201.. D. Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. Crisis.. A...

aastapäeva kogumik.. A. N. V Annual Conference of Estonian Social Sciences. De Leo. Sweden: 102:3. K..). Suitsiidikatse raskusastme määratlus ja selle seos psüühilise seisundiga [Assessment of the severity of suicide attempt and association with psychic status]. (2004). M. [WHO SUPRE-MISS control group study – suicidality in the population and problems in the society. Värnik. L.. Värnik. Stockholm. and Värnik.Kõlves. M. Kõlves. Tallinn: Iloprint: 70-73. XXII World Congress of IASP. M. (2003). Estonia. Tallinn: Iloprint: 87-90. Killarney. Sisask. Tihaste.. England: PO22. V Annual Conference of Estonian Centre for Behavioural and Health Sciences. Pühajärve. M. D. and Värnik.. A. Bolhari. M and Värnik. Raudsepp.. A. WHO SUPRE-MISS: Suitsiidikatse sooritanute psüühiline terviseseisund ja kontakt tervishoiuasutustega [Psychic health status and contact with health care services among suicide attempters].. Sisask.. A. (2004). K. WHO SUPRE-MISS: Rehabilitation for suicide attempters. Samm. (2003). Does religion pretect against suicide attempt: WHO SUPREMISS study.. Pärnu.. L. M. A. WHO-SUPRE: Ülemaailmne suitsiidikatsete uuring Eestis [WHO SUPRE-MISS: Worldwide study of suicide attempts in Estonia]. and Värnik. Nguyen. Fleischmann. Schlebusch. (2002). Stockholm.. M. Roosta. A. Sisask. Phillips. Anion. L. M.. D. D. and Wasserman. De Silva. II Annual Conference of Estonian Centre for Behavioural and Health Sciences. M. M. Raudsepp. T. J. Suitsiidikatse kajastamine meedias ja sellelejärgnenud Interneti kommentaarid [Media portrayal of a suicide attempt and following comments in the Internet].. (2007). Suicidal behaviour among young people in Estonia: A case analysis. [WHO SUPRE-MISS: rehabilitation of suicide attempters.] Suitsiidiuuringud – Suicide Studies. V. and Berolote. Kõlves. Värnik. A. A.. Värnik (Ed. M. and Värnik. Conference papers of direct importance Sisask. A. Sisask.. K. and Wasserman. ERSI 10th anniversary collected papers. D. Sisask.. XXII World Congress of IASP. D.. Estonia. Sisask. Estonia. (2003). Estonia. A.. Vijayakumar. (2005). 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]. J. 9th ESSSB. M. J. Värnik (Ed. Wasserman. Sisask. A. XXIV World Congress of IASP. and Sisask. A.] Suitsiidiuuringud – Suicide Studies. A. K. Botega. ERSI 10. J. A. 10 .. III Annual Conference of Estonian Centre for Behavioural and Health Sciences. IV Annual Conference of Estonian Centre for Behavioural and Health Sciences. aastapäeva kogumik. M. and Värnik. Tihaste... Warwick. ERSI 10th anniversary collected papers. D. Tartu. WHO SUPRE-MISS uuringu kontrollgrupp – suitsidaalsus populatsioonis ja probleemid ühiskonnas. Kõlves. Värnik.. WHO SUPRE-MISS: suitsiidikatse sooritanute rehabilitatsioon. Estonia. Sweden: 110:1. M. Ireland: OR022. Võru-Kubija. (2006). M. (2003). ERSI 10. (2003).. and Wasserman. Sisask.). Sisask. SUPRE-MISS in Estonia – main risk groups among suicide attempters.

Kõlves.. VII Annual Conference of Estonian Centre for Behavioural and Health Sciences. Sisask. A. and Wasserman. XXIV World Congress of IASP. M... Kõlves. (2009)... N. Bertolote. M. J. M. D. K. VI Annual Conference of Estonian Centre for Behavioural and Health Sciences. Konstabel. J. D.. D.. Bolhari. Bolhari.. A. M. K. L. A. Subjektiivne psühholoogiline heaolu suitsiidikatse raskusastme määratlemisel [Subjective psychological well-being in assessment of the severity of suicide attempt].. A. De Silva. Schlebusch. Kõlves. M... and Fleischmann. Värnik. N. K.. M.. Sisask. D. (2008). Vijayakumar. L. D. Phillips. Vijayakumar. Subjective psychological well-being WHO-5 in assessment of the severity of suicide attempt: WHO SUPRE-MISS study.. Religioossus kui kaitsetegur suitsiidikatse vastu: WHO SUPRE-MISS juhtkontroll uuring [Religiosity as a protective factor against attempted suicide: WHO SUPRE-MISS case-control study]. M. Kõlves. Nguyen. Värnik. Sisask. Estonia. (2007). K. Värnik. D. K.. Nguyen. Ireland: OR069. Brief intervention after attempted suicide: findings from WHO SUPRE-MISS in Estonia.. Wasserman. Bolhari. Berolote. (2008). L... A. Fleischmann. V. M. J.. Merida. N. J.. Narva-Jõesuu. J. Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. Estonia. 29th Nordic Congress of Psychiatry (Session: Best research from all countries published in Nordic Journal of Psychiatry in 2006-2008). Mexico. Värnik. Killarney. D. Schlebusch.. J. Sweden. J.. D. Toila. Stockholm. Wasserman. De Silva. Berolote. Botega. A.. 9th World Conference on Injury Prevention and Safety Promotion. and Fleischmann... De Leo.. De Leo... 11 . Botega. T.. Sisask.. Phillips. Vijayakumar. Botega. L. L. M.Sisask.... (2007). and Wasserman. A. V. T. M and Värnik. A..

established and led by Airi. whose questions. Ilkka Henrik Mäkinen and Assoc. Danuta Wasserman. but also in continuous methodological consultation. Social and Health Sciences – have supported my research mobility and enabled me to enrich the content of my PhD thesis. Danuta Wasserman) and the Research Unit in Health. I am also grateful to my external reviewers. Prof. Behaviour and Change (RUHBC) at the University of Edinburgh (thanks to Prof. and the Doctoral School of Behavioural. Prof. Dr. the Estonian Health Insurance Foundation and the Estonian Centre of Behavioural and Health Sciences. 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. comments and suggestions helped im- 12 . the Doctoral School of Educational Sciences. Many of the co-authors of the articles I have published – such as Prof. During my PhD studies. Airi Värnik and Prof. Dr. which has kindly hosted me during my PhD studies at Tallinn University. Airi has been my teacher. a dear friend who has not only helped in data processing. four different doctoral schools at Tallinn University and the University of Tartu – the Doctoral School of Behavioural and Health Sciences.ACKNOWLEDGEMENTS In my professional career as a social scientist. the Doctoral School of Social Sciences. her day-to-day company has helped me develop as a person. 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. The empirical material for my dissertation was collected within the framework of the WHO SUPRE-MISS study. Dr. Kairi Kõlves and Alexandra Fleischmann – are much more than just colleagues to me. I would like to express my gratitude to the Institute of International and Social Studies. 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. and the always optimistic and supportive Mare Raidla. Stephen Platt). Liina-Mai Tooding. 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. 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. To Airi I owe everything I am in suicidology. Mikko Kari Lagerspetz. 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. Furthermore. I highly appreciate the fieldwork carried out by the interviewers and the implementation of the SUPRE-MISS project would not have been possible without the financial support given by WHO. This dissertation has been written under the supervision of Prof. which was the first project I was involved in after joining the Estonian-Swedish Mental Health and Suicidology Institute (ERSI) research group.

my utmost gratitude goes to my immediate family – Toomas. Mats and Liisa-Lii Tamme – and my parents – Roland and Milvi Sisask – who have supported my aspirations and my commitment to this work. 13 .prove the final version of the dissertation substantially. Ats. Thanks also are due to Delaney Skerrett for his thorough linguistic revision of the dissertation. Last but not least.

PREFACE According to the World Health Organization (WHO). which coincided with the turbulent socio-political and economic changes after dissolution of the USSR in 1991. Värnik 2005. Suicide rates vary widely by continent.2 with the respective figure in the European Union being 10. 2009). suicide rates in Estonia have shown sharp fluctuations. The Wasserman and Värnik research group has substantially contributed to the evidence supporting a sociological approach to suicide (Wasserman and Värnik 1994.7 in 1994 to 16. continuous research on explaining suicidal behaviours is needed in order to provide evidence-based suicide prevention. 2000. Bertolote 2001). Tooding et al. Schmidtke et al. The research tradition on suicide in Estonia at an internationally significant level was begun by the Wasserman and Värnik research group approximately two decades ago. Nock et al. there are indications that. Värnik et al.5 in 2008. Suicidology is an interdisciplinary research area. due to methodological discrepancies and sociocultural considerations (Silverman 2006b. countries and populations surveyed becomes. In the last 15 years. 1998. 2009).0 per 100 000 inhabitants (Bertolote 2001. Wasserman et al. During this time period. 1997. Värnik and Mokhovikov 2009. Bertolote et al. across different sites worldwide. 14 . Wasserman and Värnik 2001. The spectrum of suicidal behaviours goes beyond completed suicides and includes attempted suicides and suicidal ideation (plans. 2004. Värnik 1998. As Estonia is among those countries that have an elevated risk of suicide. attempted suicides can be 10-40 times more frequent than completed suicides (Platt et al. Värnik and Wasserman 2009. Mittendorfer Rutz and Schmidtke 2009). Bertolote and Wasserman 2009. 2010). the suicide rate in Estonia has decreased dramatically from 41. culture and country. The latest available 5-year (2004-2008) average suicide rate in Estonia is 18. 1992. The prevalence of suicidal ideation has been found to vary in different sites from 3% to 25% of the total population (Bertolote et al. 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). Wasserman et al. 1996. The further from completed suicide we go on this spectrum . Värnik et al.5 (WHO/Euro MDB 2010). 2005. Värnik et al. suicide is a global public health problem with an estimated global rate of suicide of 14. 2008). However. 1998. Värnik et al. thoughts) as well (Wasserman 2001b. 2003. the more problematic the comparison of studies between and among different research groups. 2005. Bertolote et al.

though preceding suicides with certain regularity. consequently. In the 20th century. The suicide. it is a collective phenomenon and every society or social group has a certain inclination towards suicide during a given period of time. This phenomenological point of view seems to attain even more significance when attempted suicide is the research subject. the sociological method rests wholly on the basic principle that social facts must be studied as things—that is. But even when concentrating on the subjective meanings of attempted suicides. 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. attitudes and motives. Studies on suicidal behaviour with a sociological approach are often rooted in the classic theory of Émile Durkheim (1897/2002). Suicide as a social fact cannot be explained by individual-level risk factors. beliefs. as the interpretation of the suicidal phenomenon can be obtained retrospectively from the suicidal individuals themselves. developed the voluntaristic theory of social actions. as realities external to the individual. According to him. Absence of happiness in life does not necessarily cause people to kill themselves unless they are otherwise so inclined (270). 2009). Nevertheless. in order to understand the meaning of suicidal behaviours. are not the real causes of suicide. but these choices are constrained by biological and environmental conditions and by the values and norms governing the social structures in which these actions and choices occur. According to him. a representative of functionalism in sociology. to study real-world patterns of actions and meanings by exploring suicidal individuals’ inner world – their thoughts. individuals make choices in the course of their actions. cannot simply be explained by the social and general causes of the phenomenon (241). more attention has been paid to the subjective meaning of suicidal behaviour and ethnomethodologically-inspired sociological works have even questioned the ways in which information on suicide is obtained.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). Durkheim does not put emphasis on the subjective meaning of social facts. He says that individual events. Douglas (1967) highlighted the need to cease looking at aggregate levels of suicide as social fact and rather. The majority of later sociological analysis on suicide has been in the form of criticism and further development of Durkheimian structural theory. The fundamental issue is the level of social integration (egoistic versus altruistic suicide) and social regulation (anomic versus fatalistic suicide). For example Parsons (1937/1968). even Durkheim admits that all victims of suicide give the act a personal stamp which expresses their temperament and the special conditions in which they are involved. we cannot escape the fact that 15 . underlining the importance of insight into individual cases of suicide (Mäkinen 1997.

However. Postmaterial values reflect the assumption that survival can be taken for granted.these meanings are. in the conditions of ‘late’ or ‘high’ modernity. Inglehart (1997) refers to the subjective aspect of a society’s institutions. Searle 1995). values. diversity. and more the results of his or her own agency. human behaviour is heavily influenced by the culture in which the individual has been socialised. Giddens (1991/2004) has stressed the interaction between the individual and institutional forces in the shaping of the structural characteristics of the world. connections between objective reality and subjective meaning – has been the central idea of social constructionist theories (Berger and Luckmann 1966/1991. despite the high level of freedom of individual choice and the importance of subjective meanings in the contemporary world. transmitted from generation to generation and internalised by the people of a given society (15). In addition to the socialisation process and structural influences. At the same time. but rather an active agent in the construction of the reflexive project of the self. knowledge and skills that is widely shared within a society. The postmodern trajectory shifts authority away from the aggregate level to that of the individual. the self is not a passive entity determined by external influences. Inglehart (1997) introduced the concept of post-material values as a move toward a more humane society. these value systems are influenced by the individual’s everyday experiences and by the knowledge shared with others in the course of interaction. 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). with an increasing focus on individual concerns and individual subjective well-being. 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). at least two different constructionist schools of thought can be identified within research addressing social problems: ‘strict’ and ‘contextual’ constructionism. which leads to a growing emphasis on the need for self-expression. postmodern thinkers highlight the fact that the advance of material welfare in Western societies has produced a condition in which both the individual’s well-being and the limits of his or her identity are less dependent on material and structural constraints. The social construction of reality in everyday life – interaction between the social and the individual. ‘Strict’ social constructionism takes the position of a supposedly objective perspective in refusing to relate itself either to the social conditions against which the claims may be interpreted. with more room for individual autonomy. it is a system of attitudes. individuals contribute to and directly promote social influences that are global in their consequences and implications. By culture. At present. In forging their self-identities. and from norms to subjective meaning. in turn. influenced by the particular society’s changing value systems. and selfexpression (12). or to the possible interests and values behind 16 . According to him. Value systems are an important part of our apprehension of the world. Spector and Kitsuse 1987. Thus. beliefs.

it is more significant to say that they construct their own nature.such claims. or more simply. that they produce themselves. as well as Searle’s (1995). As a result. even more. the self cannot be adequately understood apart from the particular social context in which they were shaped. stating that social problems themselves are results of a subjective definition process. this approach is relevant mainly when focusing on the practices of institutional actors in defining and categorising behavioural acts as suicide attempts. The organism and. 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. 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. the act of attempted suicide becomes more intelligible if we endeavour to understand suicidal individuals’ ways of constructing their everyday reality. Human activity can be described as conduct in the material environment and as an externalization of subjective meanings (68). While it is possible to say that individuals have a nature. The viewpoint of ‘strict’ constructionism is somewhat different. Human behaviour is a product of the individual’s own sociocultural formations rather than of a biologically-fixed human nature (67). For social facts. which itself can be of interest and which needs to be placed in the context of what is known – however vaguely – about values. the ‘contextual’ approach should be discussed: It seems to lie closer than the ‘strict’ approach to the constructionist sociology of knowledge originally suggested by Berger and Luckmann (1966/1991). Biological facts serve as a necessary precondition for the production of social order (70). Spector and Kitsuse (1987) stated that social problems exist only through the enterprises of groups or individuals who create them (161). it advises the study of social problems to focus entirely on the claims-making processes themselves. interests and objective conditions. ostensibly presuming nothing about their social context. The central question for sociological theory as put by Berger and Luckmann is as follows: How is it possible that subjective meaning becomes objective facticity? According to Berger and Luckmann (1966/1991). With regard to the wider scope of social phenomena. the ‘contextual’ approach represents the interactionist and ethnomethodological tradition. everyday life presents itself as a reality which is interpreted by individuals and is subjectively meaningful to them as a coherent world. the attitude that soci- 17 . In contrast. understanding of the construction of social reality helps to conceptualise how attempted suicide as a social fact exists. It is a world that originates in their thoughts and actions and is maintained as real by these (33). 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. In other words. 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). Hence. The authors’. For our purposes.

being recognised as a social fact. That is also true for attempted suicide. 2003. Being suicidal is a reality for a person attempting suicide. but with a clear intention of self-destruction. reflected and interpreted as such by society. ATTEMPTED SUICIDE The development of suicidal behaviour has been characterised by a model of suicidal process with continuously increasing intensity. 1996. Wasserman 2001b. any meaningful definition of a suicide attempt should contain a high likelihood of death and true intent to kill oneself. In this way. not all authors have the same view on the intentional and motivational aspects of non-fatal suicidal 18 . While some researchers consider non-fatal suicidal acts as failed suicides (Farmer 1988) others consider it as a way to seek attention (Maris 1981). professional knowledge and skills as well as attitudes construct a case of attempted suicide. 2007a. a suicide attempt entails different consequences in different societies concerning treatment. For example. rehabilitation and referral. in order to understand attempted suicide as a social phenomenon. the ICD-10). all these terms have been defined in different ways and. a suicide attempt relates to actions taken against oneself and without fatal outcome. O'Caroll et al.ety takes toward the phenomenon is partly constitutive of the phenomenon (Searle 1995 :33). intentional self-harm. Suicidality is a continuum from the lowest (weariness towards life. parasuicide. 1992. Generally speaking. Bertolote and Wasserman 2009). De Leo et al. the culture. Different researchers have tried to provide the most adequate term for a non-fatal suicidal act – suicide attempt. but it becomes a social fact with all its consequences only if recognised. 2004. After doing this. What is more. objective everyday reality. deliberate self-harm.or herself counts as a suicide attempt. Hawton et al. An institutional social fact cannot exist in isolation. According to Silverman (2006a). suicidal ideation) to the highest (serious suicide attempt and completed suicide) level of suicidality (Maris et al. Further. However. subjective meaning of reality and interaction between these constructs should all be considered. Most commonly. the status of being a citizen has associated with it a whole range of functions and different societies may differ radically in the rights and obligations of citizenship. harming him. Silverman 2006a. Platt et al. no consensus has been reached between suicidologists on the best applicable term. Summarizing these general theoretical underpinnings. 2007b). 2009. Bertolote et al. Silverman et al. health care professionals’ common sense. Something is a suicide attempt because it is believed and agreed to be a suicide attempt. so far. A considerable lack of consensus exists surrounding any universal conception and appropriate terminology applicable for all suicidal acts with a non-fatal outcome. ICD-10 1990/2007. 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. non-fatal suicidal behaviour (Kreitman 1977. 2000.

2004). They claim that ‘terms such as deliberate self-harm. two definitions of deliberate self-harm (Hawton et al. 2004). which 19 . Kreitman and colleagues (1969. lifethreatening act resulting in physical injury but not in death and it does not require suicidal intent. one definition of non-fatal suicidal behaviour (De Leo et al. AAS/SPRC 2006). These alternative terms and definitions include certain similar but also certain different components (Table 1). 2007). introduced by the ICD-10 (1990/2007). He identified four definitions of suicide attempt (O'Caroll et al. irrespective of motivation (Hawton et al. 1969). 2004). there is also the term ‘intentional self-harm’. the UK. It is an act of non-fatal. without any implication about intention to die. one of suicidal act (National Strategy for Suicide Prevention 2001) and one of parasuicide (Platt et al. 2003. Attempted suicide has also been presented as a certain form of conscious or subconscious communication addressed to others and a sort of alarm signal. 2004). This model contains more reactive characteristics than communication motives. Throughout history.acts. It describes events ‘in which the person simulates or mimics suicide. A review of commonly used alternative definitions of nonfatal self-harm behaviours was recently published by Silverman (2006b). Becks et al (1974a) described a suicide attempt as a wilful. Australia and New Zealand prefer using the term ‘deliberate self-harm’. 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’. indicating an appeal for help (De Leo et al. 1992). self-injury or self-poisoning neglect the very real association that exists between attempted suicide and completed suicide’ (De Leo et al. Suicidal behaviour presents an escape from pain and occurs in situations where the person feels trapped. Deliberate self-harm includes intentional selfpoisoning or self-injury. All of them are acts with a non-fatal outcome. They considered ‘parasuicide’ to be a more descriptive term and one that could cover all deliberate non-fatal acts of self-harm. Kreitman and colleagues (1969) disagree with the usage of the term ‘deliberate self-harm’ for non-fatal suicidal acts. 2002. self-inflicted. The motive is to elicit certain expected reactions from the environment. AAS/SPRC 2006). 2003. 1977) suggested the term ‘parasuicide’. Researchers from Ireland. the concept of a ‘cry for help’ has been applied as an explanation for suicide attempts (Stengel 1962. in that he [sic] is the immediate agent of an act which is actually or potentially physically harmful to himself [sic]’ (Kreitman et al. self-destructive behaviour that occurs when an individual’s sense of desperation outweighs their self-preservation instinct (Mitchell and Dennis 2006). Goldsmith et al. 1996. In addition to the terms included in Silverman’s review. National Strategy for Suicide Prevention 2001. Maris (1981) claimed that the goal of a suicide attempt is manipulation and attention seeking. De Leo et al. Silverman 2006a) and is associated with varying levels of suicidal intent and a wide variety of motives (McAuliffe et al. In order to solve the dilemma between the terms ‘attempted suicide’ and ‘deliberate self-harm’.

’ Table 1. 2002) Suicide attempt (National Strategy for Suicide Prevention 2001) Suicide attempt (O'Caroll et al. Terms (ICD-10 1990/2007. 2004) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 20 Intention to die . 1992) Non-fatal suicidal behaviour (De Leo et al. suicide (attempted) (ICD-10 1990/2007) Suicidal act (National Strategy for Suicide Prevention 2001) Suicide attempt (AAS/SPRC 2006) Suicide attempt (Goldsmith et al. 2003) Intentional self-harm. which distinguishes them from accidents and other external injuries. 10th edition (1990/2007) was in use as an operational term: ‘intentional self-harm’ (Codes X60X84. 1996) Parasuicide (Platt et al. No matter what term is in use. Silverman 2006b) and components of nonfatal selfharm behaviours Desire to evoke changes Yes Yes Intentional (deliberate) self-infliction Non-habitual behaviour Yes Yes Non-fatal outcome Self-harm (injury. The terms ‘deliberate self-harm’ and ‘intentional self-harm’ consider factual self-harm (injury or poisoning) as an obligatory component of the definition.distinguishes them from suicides with a fatal outcome. The terms ‘suicidal act’ and ‘suicide attempt’ include intention to die or to kill oneself as a mandatory component of the definition. the description given by the International Classification of Diseases. Chapter XX). which includes ‘purposely self-inflicted poisoning or injury. they are all intentionally (deliberately) self-inflicted. Within the WHO SUPRE-MISS study. poisoning) Deliberate self-harm (AAS/SPRC 2006) Deliberate self-harm (Hawton et al. ‘Parasuicide’ and ‘non-fatal suicidal behaviour’ emphasize the non-habitual aspect of the nonfatal self-harm behaviour. and suicide (attempted).

Hjelmeland 1995. such as trying to manipulate others or escape from an intolerable situation (Michel et al. WELL-BEING In postmodern society. was devised to measure the severity of suicidal intent among suicide attempters (Pierce 1977). 2001). 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. This is primarily because it permits a distinction to be drawn between accidental and suicidal behaviour (Andriessen 2006). 1979. both on an individual and societal level – economic. social. 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. Andriessen 2006. Beck et al. there is a clear shift from survival values toward well-being values (Inglehart 1997). one example being the particular way in which a suicidal act is carried out. Subjectively meaningful suicidal intent becomes objectively available and meaningful for others after reflecting on it in an objective way. Although difficult to be observed. Helliwell 21 . Motives are related to the ‘reason for the desire’. Suicidal intent consists of a consciously expressed wish to be dead but there are also non-suicidal conscious or unconscious purposes. Suicidal intent evolves during the suicidal process and the levels of suicidal intent at different stages of the suicidal process may vary. Silverman 2006a). Suicidal intent has been defined as the seriousness or intensity of a person’s wish to terminate his or her life (Beck et al. One of the best-known scales. is not a suicide-risk scale as such. Pierce’s intention was to design and test a more objective scale for measuring suicidal intent than the BSIS but the outcome was merely a modification. Psychometric scales are available to measure levels and various aspects of suicidal intent. Wasserman 2001b). A comparable scale. The term ‘level of suicidal intent’ is used to describe the intensity of a death wish (Hjelmeland and Hawton 2004). 1974a. Andriessen 2006). suicidal behaviour has clear aspects of verbal communication but nonverbal suicidal communication also expresses suicidal intent. intent is too intimate a thing to be anything more than vaguely interpreted by another. The concept of well-being is complex and multidisciplinary in nature. Bech et al. physical and psychological (Diener and Lucas 2000. Moreover. comprising different dimensions. Hjelmeland and Hawton 2004. 1974a). According to Durkheim (1897/2002). Hjelmeland and Knizek 1999b. especially in the presence of others (Lester 2001. the Beck Suicide Intent Scale (BSIS). it even escapes self-observation. the Pierce Suicidal Intent Scale (PSIS). 1994.SUICIDAL INTENT Suicidal intent is an essential component of any definition of suicide and suicidal behaviour. Researchers report that the terms ‘motives’ and ‘intentions’ are often used inconsistently (Hjelmeland and Knizek 1999a. but rather a scale designed for use in research studies to classify suicide attempters (Beck et al.

1999. third. The WHO-5 has been found to be a sensitive and easily used instrument for depression screening in primary care (Bonsignore et al. 2003. he claims that perhaps the concern of greatest importance is the relationship between personal well-being and the broader issues of the collective wellness of humanity. is: ‘a positive and sustainable state that allows individuals. One possible way to define wellbeing relevant to different societal levels. The hedonic view equates well-being with positive emotions – pleasure and happiness – and is concerned with the experience of pleasure versus displeasure or pain. As individuals pursue aims they find satisfying or pleasurable. The five statements of the WHO-5 are supposed to measure the pure subjective psychological feeling of a person about his or her well-being. using relatively simple self-rated questions about ‘happiness’ and ‘life satisfaction’. The term eudaimonia refers to well-being as distinct from happiness per se. 2008). the concept of well-being refers to optimal psychological functioning and experience. economists and others begun to demonstrate that subjective well-being can be measured with reliability and validity. Bech et al. 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). According to Ryan and colleagues (2001. parenting and preaching. These last two constitute subjective well-being. or ‘subjective well-being’. therapy. Finally. How we define well-being influences our practices of government. they may create conditions that make more formidable the attainment of well-being by others. about the role of well-being in understanding suicidal behaviour. The need to assess the utility of the WHO-5 in the context of detecting suicidal ideation 22 . As stated by Helliwell and Putnam (2004) the ultimate ‘dependent variable’ in social science should be human well-being.and Putnam 2004. Hegerl and Althaus 2003. There is rather little research available. 2003. A relatively new instrument to measure the subjective level of people’s wellbeing is the WHO well-being index (WHO-5). stressing pleasant emotional prevalence over negative affect. well-being as defined by individuals themselves. groups and nations to thrive and flourish’. by external criteria defining what is desirable in society. Only in recent years have psychologists. given by Huppert et al (2004). 2001. although it also reflects aspects other than the simple absence of depressive symptoms (Heun et al. 2004). Huppert and Baylis 2004). in a normative way. Henkel et al. Ryan distinguishes between two approaches to subjective well-being: hedonic and eudaimonic. teaching. second. and in particular. Löwe et al. to realise valued human potential and to feel intensively alive and authentic. The eudaimonic conception of well-being calls upon people to live in accordance with their true self. 2006). Diener (1984) distinguished between three ways of formulating the definition of well-being: first. in a cognitive way. in an affective way. Kessing et al. by a person’s self-assessment of their life in positive terms (life satisfaction). to the best of the researcher’s knowledge. as all such endeavours aim to change humans for the better and thus require some vision of what ‘better’ is. developed by Bech in the 1990s (WHO 1998).

Christianity and Islam. According to him. 2006). religious knowledge and religious consequence. especially in the three monotheistic religions of Judaism.has been pointed out (Awata et al. partially due to the growing convergence of Catholicism and Protestantism (Stack 1983). Koenig et al (2001) identified twelve dimensions of religion: religious belief. thus represents a strong confirmation of the subjective well-being data. Regardless of type. rituals and symbols designed to facilitate closeness to the sacred or transcendent. but because it creates a society with a collective credo. religious commitment/motivation. 2006). religious ‘quest’. practices. organisational religiosity. Kelleher et al. A comparison between Islam and Christianity has shown that the strong degree of integration between the individual and society developed by followers of the Islamic tradition has a moderating effect on the suicide rate (Simpson and Conklin 1988. religious experience. 2007). religion in general may provide protection against suicide (Breault 1986) and the presence or absence of religious denomination may be more useful than the evaluation of an association between specific religious denominations and suicidal behaviours (Dervic et al. 2006). ‘[t]he fact that the suicide data and the measures of life satisfaction show remarkably similar structures. Different religions have different views on suicidal behaviour. In most known religions of the world. especially with respect to the effects of social capital. religious affiliation and denomination. Durkheim (1897/2002) illustrated the protective effect provided by religious denomination by way of social integration and regulation in the lower suicide rates reported in Catholic countries compared with Protestant countries. non-organisational religiosity. not due to the special nature of religious concepts. suicide is condemned. As Helliwell and Putnam (2004) point out. However. Faria et al.’ RELIGIOSITY Koenig and colleagues (2001) have defined religion as an organised system of beliefs. However. The present dissertation focuses on three dimensions of religion – religious denomination. 2004. others doubt the effect of religious denomination as a measure of religious integration and regulation in the contemporary world (Neeleman et al. Faria et al. 2004. Both Hindus and Buddhists are more ambivalent in their atti- 23 . Bertolote and Fleischmann 2002). Moreira-Almeida et al. Although several studies have supported Durkheim’s classic findings (Dervic et al. and subjective religiosity – and its associations with suicidal behaviours. religion protects an individual against the desire for self-destruction. the conservative church members (Catholic and Orthodox) have been the most outspoken against suicide with the sixth commandment (‘Thou shall not kill’) used as the official Christian statement prohibiting suicide (Pescosolido and Georgianna 1989. 1998). organisational religiosity. religious coping. religious well-being. subjective religiosity. religion is a wide concept comprised of different dimensions. 2004. Within Christianity. the strength of this condemnation has varied over time and within the religions themselves.

2006). Kelleher et al. the Islamic religion condemns on one hand and forgives on the other. Another study showed that visiting or talking with friends or relatives did not reduce the likelihood of suicide but frequent participation in religious activities did. 2000). such as serious handicap (Tousignant et al. Musick et al. as suicide terrorists do not appear to be truly suicidal and belong to a subgroup of the terrorist population (Townsend 2007). The Hindu religion tolerates suicide in situations when a person is considered socially dead already. Suicide is considered a sin and subsequently a crime but it is also a shameful act within the family and subsequently must be concealed (Khan and Reza 2000). which has been described as less formal and organised and more subjective. 2001). in turn. Inglehart 1997. individual and inwardly directed than religiosity (Koenig et al. as suicide victims are often seen as mentally ill (Simpson and Conklin 1988). can be considered protective against suicide (Breault 1986. Islam is arguably much firmer about the sinfulness of suicide than Hinduism and Buddhism. Pescosolido and Georgianna (1989) claimed that religious and other network ties alike have both integrative and regulative aspects and act. da Silva et al. personal beliefs are at least as relevant as integration into religious institutions when explaining individual and group behaviours (Stack 1983. They believe in karma.e. Church. Spirituality outside formal religion as well as the concern for the meaning and purpose of life has begun flourishing in the postmodern era (Inglehart 1997. is closely and inversely associated with suicidal behaviours (Stack and Lester 1991. 1998). Regardless of denomination. and even Christianity (Lester 2006). Siegrist 1996. 2004. 1998). Duberstein et al. Still. 2006). which suggests that something more specifically intrinsic in religious identity might be responsible for decreasing suicide risk (Nisbet et al. mosque or other important religious attendance (i. which facilitates the idea that putting an end to one’s life is not the final step (Bolz 2002).tude towards suicidal behaviours. exactly which elements of religious participation reduce the risk of suicide cannot be easily discerned. However. In postmodern societies. 2004. Hay 2002).. Moreira-Almeida et al. 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. A separate social construct known in the context of Islam is suicide terrorism. therefore. Neeleman 1998). The dimension of subjective religiosity leads us closer to the concept of spirituality. Several studies have revealed that religious commitment. The Islamic doctrine regarding suicide is well known: persons taking their own life will be denied entry into heaven. 24 . 2006). expressed in church attendance. how often someone attends religious meetings) is one of the most commonly used questions to investigate the level of religious involvement (Koenig 2005. as important sources of social and emotional support. actual church attendance can be used as an indirect indicator of religious commitment and.

The sites/countries included in the WHO SUPRE-MISS study were selected by WHO experts from the regions where less research on attempted suicides is available. These qualitative descriptions detail the sociocultural background conditions in the societies where the quantitative data on attempted suicides has been collected. and are linked with each other through a common theoretical framework—that is. employment) relevant. sociological aspects are important as well. along with the epidemiological. (3) To investigate whether religiosity.RESEARCH PROBLEM AND AIMS Sociological studies have concentrated mostly on suicide and less is known about attempted suicide as a social phenomenon. the one provided in the previous section. They are all concerned with the subject of attempted suicide. such as belonging to any particular denomination or attending church or other place of worship. marriage. not only are the structural elements of society (e. interactions in constructing everyday reality and subjective meanings given by individuals to their acts. (4) To characterise the severity of attempted suicide by extracting the components of suicidal intent and analysing levels of suicidal intent by gender. medical and psychological aspects of attempted suicides. but so too are the post-material values.and middle-income countries. (2) To describe the main characteristics of suicide attempters and their identification and referral routines at emergency departments of general hospitals in specific culturally diverse low. This dissertation is based on four articles dealing with the same empirical material. 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. especially from a global cross-culturally comparative perspective. education. and subjective religiosity – could serve as a protective factor against attempted suicide from a cross-cultural perspective (Article IV). most of the studies on attempted suicide are performed in developed countries and less research is available from low. organisational religiosity. rituals and ceremonies regarding death and the sociocultural context and attitudes towards suicidal behaviour. cultural systems. The aims of the current dissertation are: (1) To provide a qualitative description of the sites included in the WHO SUPREMISS study in respect to the sociocultural context of suicidal behaviours. The current study focuses on attempted suicide as a social phenomenon and is based on the assumption that.and middle-income countries from around the world (Article I). Moreover. Moreover. albeit from slightly different perspectives.g. assessed across three dimensions – religious denomination. age and ex- 25 . The descriptions comprise existing religious systems.

is an important piece of information about the severity of attempted suicide. measured by depression. in addition to objective external observations. measured by the suicidal intent scale. 26 . as measured by the self-reported level of suicidal intent. as measured by the WHO-5 in suicide risk assessment (Article II). Subjective psychological well-being as an important post-material value is believed to have high relevance in the assessment of the severity of attempted suicide. and the characteristics of the emotional status of suicide attempters.ternal variables indicative of the severity of attempted suicide (Article III). hopelessness and well-being scales in different gender and age groups. (5) To analyse the association between the severity of a suicide attempt. The assumption is that the subjective meaning given to the suicidal act by a suicide attempter. to test the applicability of well-being.

Bertolote et al. Durban (South Africa). 2008). Karaj (the Islamic Republic of Iran). 27 . 2009): 1. Dr. 2001). Community survey A community survey with semi-structured face-to-face interviews with randomly selected community members to identify suicidal ideation in the same catchment areas (Bertolote et al. Karaj and Tallinn) or a sector of the city (South Chennai and the Dong Da district of Hanoi). The SUPRE-MISS methodology and instruments were translated. Colombo (Sri Lanka). adapted to local conditions and pilot tested in all participating sites. The size of the target population of the catchment area ranged between 350. Within each site. One of the supervisors. Its main objective was to reduce the mortality and morbidity associated with suicidal behaviour. 203. Hanoi (Vietnam). Durban. Tallinn (Estonia) and Yuncheng (People’s Republic of China). METHODS AND DATA OVERALL RESEARCH DESIGN AND PARTICIPATING SITES In 2000. 2005). 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. August 22. 2005.000 and 2. a catchment area with a population above 250. Prof. except for Yuncheng which comprised a rural area. The research protocol was approved by the relevant ethics committee in each site. The author of the current dissertation participated in the study as a local project manager and interviewer. Community description A qualitative community description covering the sociocultural characteristics and contexts of the target communities (Bertolote et al. either the whole city (Campinas. that is. Colombo. WHO launched the Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS). SUPRE-MISS had three components (Fleischmann et al.and middle-income countries and these represent all WHO regions globally: Campinas (Brazil). 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. Chennai (India). 2009) 3.RESEARCH DESIGN. The participating sites were selected by WHO among low. Airi Värnik. In Estonia the study was conducted by the Estonian-Swedish Suicidology Institute (ERSI). 2.000 inhabitants was selected. The catchment areas of the sites were urban areas.000. Intervention study A clinical survey with semi-structured face-to-face interviews with suicide attempters seen at emergency-care departments in defined catchment areas (Fleischmann et al.000. 2005) and a randomised clinical trial to evaluate treatment strategies (Fleischmann et al. The Tallinn Medical Research Ethics Committee approved the Estonian study (decision no.

Interviews were conducted face-to-face and took place.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. King Edward VIII. In Campinas (Brazil). SUBJECTS AND DATA COLLECTION PROCEDURE All suicide attempters identified by medical staff in emergency-care settings between January 2002 and January 2004 (in Hanoi up to April 2004) within the defined catchment areas were invited to participate in the study. In Karaj (the Islamic Republic of Iran). At least 500 randomly selected community members from the same catchment areas were interviewed for the community survey. and in Tallinn the general practitioners’ lists were used. psychologists and/or psychiatric nurses. These community members also served as controls for the suicide attempters for Article IV. The survey covered the general population of the respective community. Sampling procedures are described in detail elsewhere (Bertolote et al. 2005). it was done by way of the electric power company code. All respondents in the community survey provided informed consent. These hospitals served the respective catchment areas of the participating sites. the sampling frame was the list of residents from census tracts. it was the Hospital das Clinicas. Once medically stable. the North Estonian Regional Hospital (the Tallinn Mustamäe Hospital and the Tallinn Psychiatric Clinic) participated. In Yuncheng (People’s Republic of China). In Hanoi (Vietnam). cluster and stratified sampling. the Addington. the Emam. in Chennai. A total of 4. In Durban (South Africa). the suicide attempters were asked to fill in a consent form and those who agreed were then interviewed. Dong Da. In Chennai (India) it was the Government Royapettah Hospital. Madani. from simple random to multi-stage. Durban and Hanoi. all of which are probability sampling methods utilizing different types of random selection. The sampling strategies applied varied. Saint Pault and Thanh Nhan hospitals participated. at the respective emergency-care departments. medical doctors. The interviewers were clinically experienced and specially trained psychiatrists. in 28 . In Tallinn (Estonia). In each site. Ghaem and Rajaee hospitals were involved. Their distribution by site is given in Table 2 and gender and age characteristics are given in Table 3 and in Article I. RK Khan and Prince Mshiyeni Memorial hospitals were involved in the study. it was the Yuncheng County Hospital.314 subjects were included in the intervention study. in Karaj. Universidade Estadual de Campinas. as a rule. the Bach Mai. the most adequate source and strategy for sampling was chosen: In Campinas and Colombo. The community members included in the study were chosen from the same catchment area and interviewed between 2002 and 2004. the street index was used. All information was self-reported and. In Colombo (Sri Lanka) it was the acute care wards of the National Hospital Sri Lanka.

38 0. Table 2.6 26.8 12 14 15 10 11 13 12 13 80 69 89 75 78 65 85 76 Site Campinas (Brazil) Yuncheng (People’s Republic of China) Tallinn (Estonia) Chennai (India) Karaj (the Islamic Republic of Iran) Durban (South Africa) Colombo (Sri Lanka) Hanoi (Vietnam) 29 .2 25. All were previously trained in the use of the SUPRE-MISS survey instrument.9 25.55 0.88 0.7 40.6 32.7 38.7 27. The interviewers were nurses.5 42. The distribution of subjects by site is given in Table 2 and gender and age characteristics are given in Table 3.most cases.6 34.9 14 15 14 14 6 12 10 88 84 62 73 83 84 96 Intervention study (intake) MaleAge female Mean Min Max ratio 0.95 2.5 26. where the questionnaire was mailed to respondents.3 39. 2005.41 32.1 28. psychologists. 2009).59 0.95 0. Total number of subjects participating in the SUPRE-MISS study Community survey 516 500 500 504 500 684 2280 5484 Intervention study Intake part of All parts of questionnaire questionnaire 162 162 120 120 469 332 680 680 945 632 570 570 1067 300 301 143 4314 2939 Site Campinas (Brazil) Yuncheng (People’s Republic of China) Tallinn (Estonia) Chennai (India) Karaj (the Islamic Republic of Iran) Durban (South Africa) Colombo (Sri Lanka) Hanoi (Vietnam) TOTAL Table 3.52 0. medical students.85 0. A detailed description of the subjects and results is published elsewhere (Bertolote et al. medical doctors.3 25. Bertolote et al.48 0.09 0. interviews were conducted face-to-face with the exception of Colombo. Gender and age characteristics of subjects participating in the SUPRE-MISS study Community survey MaleAge female Mean Min Max ratio 0.80 0.62 0. family health workers and public health professionals.72 0.93 41.

Hanoi (Vietnam). The data describe participating sites as at 2002. 3. the objective recorded data in combination with information gathered from key informants or focus group members were used. In Articles II and III. 2. 2009). Karaj (the Islamic Republic of Iran) and Tallinn (Estonia).According to the study protocol. false) and the total score has a theoretical range of 0 to 20. Negative attitude towards the future was assessed on the Beck Hopelessness Scale (BHS) (Beck et al. A higher score refers to a more severe depressive status. It included a detailed intake section comprising the method of the suicide attempt. Assessment of well-being was performed using the WHO well-being index (WHO-5) (WHO 1998). a revised version of the original Pierce Suicidal Intent Scale (PSIS) was used in the measurement of suicidal intent (Pierce 1977. The five statements presented (‘I have felt cheerful 30 . The scale consisted of 12 questions with a possible total score ranging from 0 to 24: the higher the score. mostly in those cases where the country is more or less monocultural in structure. where the questionnaire was completed by a social anthropologist. in the current research. Fleischmann et al. The SUPRE-MISS questionnaire for suicide attempters is included in Appendix 1 and the SUPRE-MISS community survey questionnaire appears in Appendix 2. WHO 2002). In Article II. The possible range of scores was 0 to 63. a higher score refers to more severe hopelessness. Chennai (India). as well as sociodemographic information and results from different psychological scales (WHO 2002. the community description data was collected by the principal investigators. the Aish & Wasserman scale (Aish and Wasserman 2001). 1961). the following scales were used for measuring the psychological status of suicide attempters: 1. In answering the items. The Aish & Wasserman scale consists of one statement (‘‘My future seems dark to me’’). Detailed community description data were available for analysis from six participating sites: Campinas (Brazil). The original scale consists of 20 statements to be rated dichotomously (true vs. physical consequences. 1999) of the WHO/EURO Multicentre Study on Suicidal Behaviour was translated and pilot-tested in each country. The exception was Colombo. 1974b) and on its one-item modification. it was impossible to extract a strictly site-specific description and the data are presented for the whole country. The occurrence of depression was assessed using the means of the 21-item Beck Depression Inventory (BDI) (Beck et al. In some cases. INSTRUMENTS The questionnaire. based on the European Parasuicide Study Interview Schedule (EPSIS) (Kerkhof et al. the qualitative community description had to be conducted by a person experienced in the field. In most of the participating sites. the type of care and referral as determined by the medical staff. To be in line with other scales used which are measured in the opposite direction. Colombo (Sri Lanka). the more severe the suicide attempt.

and in good spirits’. ‘I have felt fresh and rested’. binary and multinomial logistic regression analyses were performed and an odds ratios (OR) calculated with a 95% confidence interval (95% CI). Qualitative community description data were collected by means of a separate. which appears in Appendix 3. Greek Orthodox. the differences between groups were evaluated by a chisquare test. with a possible total score varying from 0 to 25. ‘I have felt active and vigorous’. the procedure of principal components with varimax rotation was used. Buddhist. Muslim. 2009). For categorical variables. yes. The questionnaire comprised a broad listing of sociocultural and community indices and dimensions. in terms of potential risk or protective effect of religiosity. rituals and ceremonies regarding death.0). 2–3 times a year. sociocultural context and attitudes towards suicidal behaviour. almost never. DATA ANALYSIS The sociocultural indices relevant as background for the current dissertation were extracted from the qualitative community description data. (2) How often do you go to church (or other place of worship)? Response choices were: At least once a week. ‘I have felt calm and relaxed’. other. (3) Do you consider yourself to be a religious person? Response choices were: no. once a month. Protestant. A higher score refers to greater well-being. Statistical analyses were performed with the SPSS program (version 14. The content was restructured and assembled under the following subtitles: religious systems. 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.05. The content and face validity of the questionnaire were evaluated in pilot studies and adapted to the specificities of the local cultural if needed. Hindu. Fleischmann et al. To extract the factors of the Pierce Suicidal Intent Scale (PSIS). Catholic. ‘My daily life has been filled with things that interest me’) were assessed on a 6-score scale (from never to always). For Article IV. 31 . specially designed instrument (questionnaire) (WHO 2002. To estimate the associations between the cases (suicide attempters) and the controls. Jewish. about once a year. both the suicide attempters and controls were asked the following religion-related questions: (1) What is your religious denomination? Response choices were: none. The level of statistical significance was set at α = 0.

7 countries 2002-2004 Suicide attempters (n = 2819) Controls (n = 5484) 32 . the WHO well-being index (WHO-5) Cronbach’s α = 0. the reliability of the scales was assessed using the internal consistency coefficient. Cronbach’s alpha.93. Beck Hopelessness Scale (BHS) Cronbach’s α = 0. Description of data and analysis methods applied in the current dissertation Article Article I Fleischmann et al.77) and for the other scales very good: Beck Depression Inventory (BDI) Cronbach’s α = 0. Table 4. Estonia 2001-2004 Suicide attempters (n = 469) Methods Descriptive statistics Article II Sisask et al.For Articles II and III. Spearman’s rank correlation coefficient was calculated to examine the strength of the relationships between different the variables. principal components with varimax rotation Descriptive statistics t-test Analysis of variance (ANOVA) Spearman correlation coefficient Descriptive statistics Chi-square test Binary and multinomial logistic regression analysis Article III Sisask et al. 2009 SUPRE-MISS. 2010 SUPRE-MISS. 2005 Data SUPRE-MISS. 8 countries 2002-2004 Suicide attempters (n = 4314) SUPRE-MISS. Estonia 2001-2004 Suicide attempters (n = 469) Article IV Sisask et al.93. The internal consistency of the Pierce Suicidal Intent Scale (PSIS) was good (Cronbach’s α = 0. 2008 Internal consistency coefficient Cronbach’s alpha Descriptive statistics t-test Analysis of variance (ANOVA) Spearman correlation coefficient Factor analysis.91.

Rituals and ceremonies regarding death. Suicide is seen as an act resulting from mental illness and/or moral weakness. The main religion is Christianity. Toward suicide attempters. 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 33 . generating strong emotional appeal and popularity among teenagers. political and cultural context. a more comprehensive and restructured description is provided. afterwards. an attitude which is influenced by the local religiosity. Sociocultural context and attitudes towards suicidal behaviour. Nevertheless. the family of a suicide victim is seen socially outcast and as partly to blame for the suicide. there is a lot of variation but there is usually intensified support and attention. is buried. After death. Usually. a large social difference (with a good education being only for the privileged few) produces critical life conditions for the lower class. in contradiction to the fact that more than 90% of the population believe in life after death. religion produces a consoling vision as ‘the kingdom of God is for the poor’. The subject of suicide is common in teen popular culture. Death is seen as something tragic. it is seen as a serious offence that could impede ascension to heaven. in songs of groups like ‘Legião Urbana’ and others. There is great religious tolerance and the various religious groups get on well. counterbalancing the religious influence present among members of this class with regard to suicide.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). The most common feelings toward a person who commits suicide are pity and moral condemnation. Below. There is no evident differentiation or discrimination in the funeral ceremonies for people who has committed suicide. The places of worship are Catholic churches and Pentecostal temples. combined with some criticism and hidden anger. which pro- * References to Articles I-IV are marked as follows: (‘aa’/’bb’). the deceased is watched over for nearly 12 hours. In the social. suicide is condemned and seen as an act resulting from a moral disease or weakness and/or spiritual problem. Sometimes. approximately 60% of the population are Catholic and about 25% Pentecostal. Campinas (Brazil) Religious systems. He or she is exposed to family and friends in a coffin and. Religion should repress suicide and in the Catholic and Pentecostal religions.

especially among educated young people. attitudes toward suicide have not been as rigid as among Catholics. although they do not usually get the appropriate mental help with the exception of the seriously mentally disturbed. but euthanasia has not been legalised. The constitution declares religious freedom for every citizen. Rituals and ceremonies regarding death. Religious people comprise 29% of the population. The conviction that those people could be helped is accepted. because most Estonians have been Protestants (Lutherans). in Estonia. In folklore.g. they choose to escape instead of solving their problems. Tallinn (Estonia) Religious systems. The attitude that suicide is an acceptable end to life. In terms of people’s attitudes. for various philosophical reasons. Previously. is widespread. there is no difference in the burial ceremony. The main religion is Christianity: Lutherans (46%). people feel confusion. Sociocultural context and attitudes towards suicidal behaviour. irresponsible and egoistic. The general attitude towards a person who committed suicide is ambivalent – is it weakness or strength? On the one hand. suicide has been seen as a sin and suicide victims mourned without religious ceremony. people feel sorry for them and accept it with compassion. Karl Ristikivi. the Soviet Union denied religion. suppressing its role in society. There are many Lutheran churches. The general attitude towards the family of the person who has committed suicide is compassion and condolence. the community is tolerant to different religions. there is the opinion that those who commit suicide are weak. it has largely changed because of the more open discourse on the issue in society. support and care are intensified. Nowadays. the general attitude towards suicide attempters was rejection. in Estonia suicide is accepted if the person who committed suicide had a serious somatic illness. they do not 34 . Community members’ perceptions of death and afterlife are ambiguous and there is a lot of ambivalence. Nevertheless. Catholicism and other forms of Christianity. Religion is separated from the state but has some involvement in social services through support services to victims of violence. burying is traditional but cremation is acceptable as well. Orthodox (44%). one can choose a religious or non-religious type of ceremony. Traditionally. There are no religious conflicts among groups. suicide is referred to as the devil’s temptation. etc) suicide is described as one of the possible reactions to critical life events without any negative judgment. 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. During the time of Soviet occupation. On the other hand. the novels of Anton Hansen Tammsaare. which probably supported the increase in suicide rates.duces hidden anger in the family members but. Historically there was no religious service for someone who committed suicide. At the same time. In national literature (e. Today. usually. In terms of rituals and ceremonies regarding death.

but religious suicides were. people are more sympathetic towards them. The main religion is Hinduism (85%). In the Hindu religion. The majority of works of literature portrays suicidal behaviour as a way of coping with life stressors. the attitude towards suicide in India has been inconsistent. even today. At the same time. Apart from the usual rituals. Suicide is perceived as an impulsive. The mourning practices of Christians and Muslims are similar to those among Christian and Muslim communities in other parts of the world. A significant proportion–almost 11%—of suicides in India is committed by self-immolation. Arranged marriages are still prevalent in India and there is hesitation in marrying into a family where suicide had occurred. There is a certain amount of rejection. Literature also depicts suicide. The attitude has been one of non-acceptance of general suicide. It is viewed more as a social problem. mostly accepted. Television and movies have tremendous influence over the masses and suicide is often depicted. but rarely. Traditionally. epics and folklore tales depict many instances of suicide and some suicides have even been glorified. People who commit suicide are considered as persons who brought shame to the family and hence there is rejection and anger towards the person who commits suicide. such as problems with a mother-in-law or daughter-inlaw or a failure in love. anger and ridicule. Chennai (India) Religious systems. Rituals and ceremonies regarding death. It is a mixture of support. there are special rituals performed for the person who committed suicide. cathedrals). churches. emotional act. There were many instances of religious suicides in India like ‘sati’ and ‘sallekhana’ (practiced by the Jain community). Sociocultural context and attitudes towards suicidal behaviour. The belief is that the souls are not liberated and thus left to wander around on Earth. however. Around 85% of self-immolations are by women. One of the historical reasons for the high self-immolation rate could be because of ‘sati’. historically. Hindu-Muslim and Hindu-Christian conflicts do occur. which existed in India. This attitude will probably also change because of the increasingly open discourse and suicide survivors’ support groups which are now established in Estonia. Family members also partake in these rituals and generally do not avoid the ceremonies. Suicide is not perceived as a major health issue. Scriptures like Upanishads and Vedas denounce suicide. If the suicide is due to some special social reason. 35 . shrines. Another possible response towards survivors is to lay blame. There is a mix of attitudes towards a person who has attempted suicide. There are a large number of places of religious worship (temples.know how to behave with the survivors and the result is avoidance. Christianity (6%) and Sikhism. Other formal religions are Islam (8%). This is why some additional rituals have to be performed: So that the tormented soul can attain bliss. death is followed by cremation and accompanied by 13 days of rituals and ceremonies.

Karaj (The Islamic Republic of Iran) Religious systems. the Anglican Church. conflicts have arisen between Buddhists and Muslims. and an attempt to keep it secret. Violent conflicts between Hindus and Muslims have occurred in parts of the Eastern Province. Suicide is considered 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. Of the Christian denominations. Violent conflicts between Muslims and Buddhists have arisen in Colombo. Religious rituals and ceremonies regarding death vary from one ethnic and religious group to another. The official religion in the country is Islam with Shia being the official denomination. Other formal religions present in the country include Christianity. Rituals and ceremonies regarding death. mostly over issues of sacred space. that is. from life to the afterlife. Buddhists and Christians and Muslims and Hindus. However. Sri Lanka has four major religious orientations: Buddhism (main religion). Sociocultural context and attitudes towards suicidal behaviour. But these are generally political conflicts that tend to be seen as confrontations between religious groups. Religious belief has kept the rate of suicide low. the Catholic Church predominates. while the Methodist Church. in certain specific local contexts. Rituals and ceremonies regarding death. They consider death as a transition from one life to another. The general reaction towards a person who commits suicide is sympathy. There are many religious worship places in the Islamic Republic of Iran but exact data are not available at this time. the attitude is sympathetic and supporting and there is a willingness to help. they are givien advice and sometimes criticised. Interreligious conflict does not exist as a regular or recurrent pattern in the country. although sociopolitical views and conditions mean that actual suicide rates have been kept secret. Judaism and Zoroastrian. In 36 . The usual burial and mourning practices are carried out for those who have committed suicide. More than 98% of the population in the Islamic Republic of Iran is Muslim. A person who attempts suicide but survives is treated with sympathy. condemnation. Hinduism. these practices are also linked to beliefs in life after death. In the case of Buddhists and Hindus. Towards the family members of a suicide victim. All religions practiced in Sri Lanka have the standard mourning rituals as part of their rites of passage. There are no significant conflicts between different religious groups. care and support. Perceptions of death and the afterlife are religious in nature. anger. Colombo (Sri Lanka) Religious systems. the Baptists and others also have a presence. mostly in the context of Muslim opposition to the taxation imposed by the Liberation Tigers of Tamil Elam (LTTE). It would be virtually impossible to give an accurate figure of the number of religious sites in the city of Colombo or the country in general. Islam and Christianity.

even relatively reasonable or rational practices such as euthanasia under controlled conditions are not ideologically acceptable to most people. whatever their doctrinal position on suicide might be. In terms of religious and cultural practices. the notion of shame over-determines many issues. despite the fact that suicide is one of the main social problems of the country. ritualised political suicide has become a feature of the contemporary politics of violence. suicide has not been seen in any positive light under any circumstances. Here. including funeral practices. on one level. suicide has not been encouraged by any of the ethnocultural groups living in Sri Lanka. There is always a sense of guilt within the family. Generally. Still. The exception is the highly ritualised and almost religious-like acceptance of suicide as a political weapon within the LTTE. Traditionally. This has been possible under conditions of extreme social and political control within this group and the kin of suicide bombers are well looked after by the LTTE. but on another level. there are no restrictions on either mourning or burial practices for the victims of suicide. suicide was offered as a prescriptive end to life under very specific circumstances. Thus. dating from the 1950s. Furthermore. Their mourning rituals.g. families where suicide or attempted suicide have taken place would like to keep that information out of public circulation if possible. namely by way of the suicide bombers of the militant group of the LTTE. 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. Caring and support would depend on what a family or community is capa- 37 . The only literature of the ancient (pre-colonial) period that dealt with suicide are the Hindu epics. The exceptions to this rule are the LTTE songs and theatre that glorify the ritualised suicides of its members as a political weapon. suicide is a phenomenon largely related to modernization and the social upheaval brought about by that process. love. particularly with regard to notions such as chastity and sati. film and theatre do not deal with suicide as a mainstream issue. suicide is treated with sympathy rather than with condemnation or anger. 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. marital problems) within conventional family structures. songs. The most common causes of suicide include failure in sexual or marital relationships. Within the cultural traditions of Sri Lanka. In Sri Lanka. suicide is seen like any other extreme misfortune of a personal nature that might befall a family. As such. literature. Attitudes towards suicide attempters depend on the specific circumstances.general. lack of success at examinations and sometimes simple arguments. Sociocultural context and attitudes towards suicidal behaviour. 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. Hindus and Buddhists have a strong belief in life after death. Currently. take this aspect into account. This is indicative of society’s lack of inclination to deal with this in public. although suicide can be involved as a secondary theme. sex.

Towards family members of the suicide victim. 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.’ Some bonzes (Buddhist monks) have the ability to die by stopping their breathing. Sociocultural context and attitudes towards suicidal behaviour. No major religious conflicts occur between different groups. according to Confucian concepts. who jumped into the Hat river when they were defeated by Chinese invaders. Nevertheless. Thich Quang Duc. while the majority of others practice traditional rituals and ceremonies at home and some at pagodas. Recently.ble of providing in terms of resources and the knowledge available to them. such as the two bonzes in the Dau pagoda. there has been sympathy for the suicide of the two women heroes. Trung Trac and Trung Nhi. Historically. there is a general sense of sympathy. Party members are not officially allowed to practice ceremonies in pagodas and churches. Euthanasia has not yet been accepted in Vietnam although some people express their favourable views towards it. burned himself to defend Buddhism and has been considered a hero. the current life is more important. Hanoi has Buddhist pagodas. Hanoi (Vietnam) Religious systems. The two main religions in Hanoi are Buddhism and Catholicism. Professional help is generally not easily accessible in Sri Lanka. Vietnam is a highly secular country where most of the people are non-religious. Protestant churches. However. including ceremonies at Christian churches. The burial and mourning practices in Vietnam for someone who has committed suicide are not different in comparison with those for other persons. 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. particularly in rural sectors and in the north-eastern provinces devastated by war. the practice of religion is free for all people. Religious rituals and ceremonies after death are the usual religious rituals for Christians. but no religious affiliation patterns or rates are recorded. just as living in another house while death is the return to the real house. and so on. 38 . Buddhism has a clear concept of life and death: ‘This life is just a journey. It is not uncommon to perceive survivors of attempted suicide as ‘weak’. temples from various cults. But there are also lingering thoughts as to what lead to the suicide and the resulting gossip. they sat to pray until their death and their bodies have been preserved until now. The attitudes of Vietnamese people towards the act of committing suicide are quite diverse. The official concept of the ruling Communist party is materialism. In general. But Buddhism does not influence the frequency of suicides. Catholic churches. it depends on the reason for committing suicide. Rituals and ceremonies regarding death. Vietnam used to be a Buddhist country. Many Vietnamese live according to the principles of Buddhism and believe that there is another life after this one.

The general attitude in Vietnam toward the family members of a suicide victim is a feeling of distrust. 39 . only gender and age are known. Sympathy is expressed when the reason for the suicide is a common cause. However. Sociodemographic characteristics In all sites. 2004). such death or a lost love.002). df = 1.6 (74/1472). it is known for Tallinn that the suicide attempters enrolled in the intake interviews constituted 53% of all suicide attempters seen at the emergency department during the study period (469 out of 884). in Tallinn the proportion was 66% (71/1469). 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.480). 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 number of these non-enrolled cases. The difference in mean age between enrolled and non-enrolled suicideattempter groups was not statistically significant (t = 0. Criticism is expressed when the reason for suicide is not implementing a responsibility. which is similar to that reported in the WHO/EURO multicentre study (Schmidtke et al. ranging from 51% (Chennai) to 71% (Durban). more female than male suicide attempters presented themselves at emergency-care departments. Later thorough analyses specifically addressing sampling issues revealed that. among the suicide attempters enrolled. Condemnation is expressed when the reason for the suicide is not being able to bear a difficult situation. such as not paying a debt. The male : female gender ratio in the eight countries ranged from 1 : 1. The difficulties in enrolling all eligible patients in the intake resulted from inadequate recording of emergency room visits. p = 0.7. Of those who did not participate. 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).and middle-income countries. p = 0.1 to 1 : 2. This is the first study to provide detailed information on cases of suicide attempts from a wide range of low.7. such as death for defending a value.The general attitude of Vietnam toward a person who commits suicide depends on the reason for the suicide. The general attitude in Vietnam toward a person who attempts suicide is very complex. intentional misreporting of suicides as accidental by patients and family members. females were slightly overrepresented (χ² = 9. CHARACTERISTICS OF SUICIDE ATTEMPTERS The main characteristics of suicide attempters included in the study are described in Article I.

Self-poisoning – which accounted for 69–98% of all cases – was the predominant method in all sites. Phillips et al. With the exception of Yuncheng (where men had a higher level of educational attainment than women). 2002b. Mann et al. Thanh et al. 2000. Colombo and Hanoi) and in Campinas. 1996. suggesting that marriage is not a strong protective factor against suicide attempts in developing countries (74/1472). 2005) (74-75/1472-1473). Except for Durban and Karaj. was rarely applied. More than one method. a combination of methods. Gunnell and Eddleston 2003. Phillips et al. and from 23 (Karaj) to 33 years (Yuncheng) among males (29 years in Tallinn). Eddleston and Phillips 2004). the patients were young. 1996. Latha et al. Campinas and Tallinn were the only sites where the median age of females was higher than for males (71-72/14691470). Schmidtke et al. Unlike reports from developed countries (Löhr and Schmidtke 2004). the educational achievement of male and female suicide attempters was similar (72/1470). that is. The median age among females ranged from 21 years (Durban) to 30 years (Campinas. ‘hanging’. far exceeding the other methods of ‘cutting’. 2005). The other common employment categories were ‘unemployed’. Main method of attempted suicide The method of attempted suicide was registered according to the ICD-10 (1990/2007). The one exception was in Tallinn. 22% females) and in Tallinn (13% males. 40 . Pesticide ingestion was a more common method in Asian sites (Yuncheng. Divorce was common among suicide attempters in Campinas (18% males. This is similar to results found in developed countries (Diekstra 1993. Hulten et al. 15% females) (72/1470). 2002a. It has been repeatedly shown that restricting access to and the availability of the prevailing method can be effective in reducing the frequency of suicide attempts (Bowles 1995. where 11% of the suicide attempters combined self-poisoning by alcohol with another method (72/1470). except for Campinas. Suicide attempters were more likely to be single than married among males in six countries and among females in four. Yuncheng and Tallinn). These findings strongly support earlier reports on the role of pesticide poisoning in attempted and completed suicide in developing countries (Latha et al. In all sites. Roberts et al. female attempters were more likely to be married than male attempters.Overall. In most cases. ‘housekeeper’ and ‘full-time student ’ (72/1470). 1996. Chennai. and so on. the majority of subjects were employed full-time or part-time at the time of admission to the emergency-care departments. self-poisoning involved the ingestion of pesticides or medications. Eddleston 2000. a high proportion of the subjects in this study were married at the time of their attempt. 2003.

in most of the sites it was very low (0–8% of cases). 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.Consequences of attempted suicide and aftercare Suicide attempters form a pool from which many future suicides emerge (Hulten et al. 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. Among other factors. less work has been done in developing countries. Even in those places where psychological or psychiatric services were available. RELIGIOSITY AND ATTEMPTED SUICIDE Article IV investigates the effect of religiosity on suicide attempts from a crosscultural perspective. transfer to a psychiatric institution ranged from 0% to 34%. 2000). In Hanoi. In four of the eight sites. Due to conceptual and methodological discrepancies. less than one-third of subjects received any type of referral for follow-up evaluation or care. Colombo and Karaj. while the majority of studies has been conducted in developed countries and is based predominantly on US data. Furthermore. Although exceptional and controversial findings on this issue cannot be denied. research findings on the impact of religiosity on suicidal behaviour have tended to favour the idea of an inverse association and protective effect. Since Durkheim (1897/2002). Chennai and Campinas. most subjects required a combination of medical attention or surgery but there was no danger to life (74/1472). In the remaining sites. In Campinas. The majority of studies has been ecological by design and relatively few individual-level findings have been reported. The relative lack of professional services for referral of suicide attempters results in a situation where care is limited to somatic symptoms only. psychiatric assessment and referral were not delivered in a systematic way or as part of the routine established by a European study regarding young suicide attempters (Hulten et al. the degree of non-referral was also dominant (47– 82%). This notion underlines the importance of competent and adequate assessment and care after attempted suicide. referral was primarily made to a general health-care or primary health-care centre. In these places. Bertolote and Fleischmann 2002). 2000). within the 41 . In Durban and Tallinn. With regards to the type of care. most studies performed so far are difficult to compare. the current situation leaves plenty of room for improvement in health services (75/1473). religious context has been recognised as a major cultural determinant of suicidal behaviour (Stack 2000. with the exception of Campinas and Tallinn. the patients were mainly sent to a psychiatric out-patient clinic (74/1472). a higher level of religiosity generally indicates a lower level of suicidality.

Islam (Shi’ite) in Karaj. In Hanoi. In Article IV. Moreover. Even with clinically experienced and specially trained interviewers. therefore no specifically designed scales were included in the questionnaire. or in more secularized societies (Vijayakumar et al. Another limitation is that religiosity has other aspects. The information regarding religiosity was collected from investigated subjects by asking direct questions. 2005. the results of the study cannot be interpreted without keeping in mind the low reliability of selfreported information about sensitive issues. The study on the association between religiosity and suicide attempts has at least two limitations. A recurring problem in sociological work is the confounding effect of the various other characteristics under investigation. These other dimensions of religiosity. the following sociodemographic control variables available from the SUPRE-MISS instruments were included in the regression analysis in order to statistically control for them: age. both religion and suicidal behaviour are social constructs and consequently dynamic across eras and cultures. First. various denominations without any of them prevailing in Durban. and these were not assessed by the SUPRE-MISS instrument. in Tallinn. Protestantism and Orthodox. rather than the primary focus (Flannelly et al. gender. which may act as buffers providing protection against attempted suicide and thereby lower the significance of the effect of religiosity (Stack 2000). and Buddhism in Colombo. 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 religiosity. 42 . most of the people reported no religious denomination (101-102/48-49). Measuring religion with a single question is a general limitation of studies in which religion is a minor or incidental variable.Eastern cultural system. as described by Koenig et al (2001). employment and education. may also play an important role in some cultures. Religious denomination The SUPRE-MISS sites differed substantially across the religiosity-secularity spectrum and the prevailing religious denominations across sites also varied to a large extent. The predominant religions were Catholicism and Protestantism in Campinas. Hinduism in Chennai. as well as spirituality. in addition to a great amount of people without any religious denomination. marriage. To the best of the author’s knowledge. However. 2004). Most of the major religions in the world were represented. Colucci and Martin 2008. Stack and Kposowa 2008). all-powerful factor associated with suicidality. the complexity of suicidal behaviour and the knowledge that religiosity is not a singular. Article IV is the first individual-level study to be conducted concurrently in culturally different sites. the SUPRE-MISS study was not specifically designed to study the effects of religion on suicidal behaviours.

51. There is a variety of ethnic groups and an even greater variety of cultures within each of these groups. 95% CI = 0. Subsequently. Subsequently.86. 1998). and in Islamic Karaj. the lifetime prevalence of suicidal ideation among Protestants was lower than among Catholics (104/51). Religious denomination is one of the most widely used measures of religion in medical research. Organisational religiosity demonstrated a distinctly protective effect in Campinas. in Brazil. In a very secular community. religious denomination had no effect against attempted suicide. However. In Campinas.90) (102/49). Estonia is rather secular but still a predominantly Christian country. 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. attending church or other place of worship weekly.72) (102/49). such as Hanoi in Vietnam. 95%CI = 3. religious denomination had no effect on suicide attempts in Campinas but it can be assumed that Protestantism could neutralise the protective effect of Catholicism. family and culturalgroup levels (Wassenaar et al. monthly or yearly. where it was more likely to be reported by the controls than the suicide attempters (OR = 0. the two most 43 . Durban was the only site where religious denomination showed a risk effect (OR = 5. there is a large diversity of religious denominations and this does not seem favourable in terms of providing protection against attempted suicide (105/52).15-10. is inversely associated with the suicide rate (Ellison et al. no effect of organisational religiosity on suicide attempts was detected in Colombo or Durban. A protective effect of religious denomination emerged only in Tallinn. this is only speculation. a predominantly Christian site. However. However. However. Colombo and Karaj. all controls and/or suicide attempters had some kind of religious denomination therefore the odds ratio was not calculable. There is a study available which demonstrates that religious homogeneity. Catholicism was more frequent among the control group than among suicide attempters and Protestantism was more frequent among suicide attempters than among controls. the interaction of cultures results in the blurring of cultural norms and boundaries at the individual. the effect of religious denomination was statistically nonsignificant. a study by Botega and colleagues (2005) found that. 2004). The results across the different SUPRE-MISS sites were controversial. While cultural diversity is seen as a national asset. Also in Campinas.In Chennai. 1997).37-0. South Africa has been described as ‘‘The Rainbow Nation’’ because of its cultural diversity. This study analysed Christianity as a whole as differentiating the effect of denominations within Christianity was not the issue of interest. the other Christian community. that is. which increases social interaction and social bonds between individuals with shared cultural values. Organisational religiosity The second dimension of religiosity under study was organisational religiosity.

As mentioned above. In Durban. One possibility to measure the severity of a suicide attempt is to use different self-rated psychometric scales.10-0. the risk effect of subjective religiosity was an exceptional result (OR = 2. as was also true for the effect of religious denomination (103/50).17-0. However. Aspects of suicide risk like suicidal intent. 95%CI = 0.71. this can be explained by the cultural diversity. In Tallinn.86). 95%CI = 0.17. previous research has suggested that the level of suicidal intent appears to be a 44 .37-0.29). depression. Karaj (OR = 0. subjective religiosity seems to be the crucial dimension of religiosity (105/52). 2000). the meaning of the frequency of church attendance within different cultures needs further explanation (102-103. the effect was statistically non-significant. In our postmodern world. not against attempted suicide (Vijayakumar 2003). the meaning of going to church and.54. self-worth and other positive emotions thus providing a sense of meaning and fostering feelings of control and the ability to manage difficulties (Flannelly et al. Bech and Awata 2009).82) and Colombo (OR = 0. It is known from previous research that.heterogeneous sites of religious denomination. 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. yearly visits had a protective effect and weekly or monthly visits remained statistically non-significant. at the same time. given its inability to reflect the dynamic nature of suicidal behaviour (Lyons et al.36.77).44-0. in India. a complicated task. It may mediate health outcomes through engendering feelings of self-esteem. Chennai and Hanoi. in Chennai and Hanoi. However. 52). subjective religiosity protects against completed suicide.75). In two sites (Chennai and Hanoi).105/49-50. 2001. even more specifically. 95%CI = 0.60. 95%CI = 0. Suicide risk assessment is an important issue and. The question has arisen whether a tool developed to measure suicidal intent for research purposes should be used in the same way in practice. To interpret these results. Subjective religiosity is a very informal and deeply subjective psychological construct. 2004). heterogeneity and blurring of cultural norms within the site. hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure (Bech et al. Tallinn (OR = 0. only monthly visits served as a protective factor while weekly and yearly visits were statistically non-significant. Somewhat confusing results on organisational religiosity came from Tallinn. The results from Hanoi can be attributed to Vietnam’s secularity. which may influence the overall way of thinking and mentality. 95%CI = 1.90-3. ASSESSMENT OF THE SEVERITY OF ATTEMPTED SUICIDE Articles II and III deal with the assessment of the severity of attempted suicide.

2000.5 (Schmidtke et al. new scores characterising the components of suicidal intent were calculated. long-term preparations and suicidal communication. Niméus et al. information about suicidal intent is still valuable in clinical suicide-risk assessment (Harriss and Hawton 2005). All these components are important indicators in characterising the nuances of the suicidal process before the suicide attempt. 2002. 2002. Although a higher level of suicidal intent at the time of the suicide attempt has been found to be a risk factor for possible future suicide. significant gender differences have been observed. Denning et al. Nevertheless. Two broadly common factors of suicidal intent. In Europe. Factorial structure of the Pierce Suicidal Intent Scale (PSIS) In Article III. 1991) or finding no gender differences (Dyer and Kreitman 1984. Wasserman 2001b). males and females seem to have similar levels 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). Gender differences in suicidal intent According to the results of Article III. The importance of direct and indirect. Niméus et al. verbal and nonverbal communication in the development of the suicidal process has been recognised before (Lester 2001. short-term and immediate preparations. it is conceded that a Suicidal Intent Scale cannot forecast which specific patients will die by suicide. 2004). Suominen et al. In the epidemiology of suicidal behaviour. referred to differently in other studies. These four components were the following: consciously expressed purpose and opinion about potential lethality of the act. The factor termed Alcohol/Drugs in the present study was distinct from factors in other studies (91/140). known as Circumstances. As stated in a previous study. 2003. were expected lethality (described in the present study as the Wish to Die) and planning (Arrangements and Circumstances in the present study). Hjelmeland et al. There is also a 45 . what patients say should have implications when intervention and follow-up are considered (Hjelmeland 1995).powerful predictor of eventual suicide after attempted suicide (Hjelmeland 1996. 2002. Previous research on suicidal intent has yielded different results: Some have shown higher scores among males (Haw et al. Hjelmeland and Hawton 2004). the PSIS variables were grouped into four factors that described 62. and the role played in the current suicide attempt by alcohol and/or drug consumption.1% of the total variance. and these aspects also characterise the level of suicidal intent of suicide attempters in the present study. the average male-to-female suicide ratio is 4:1 and the male-tofemale attempted-suicide ratio is 1:1. 2005) but there are also studies showing higher scores among females (Hamdi et al. expressed as Alcohol/Drugs (89/138). Harriss et al. termed Arrangements. termed a Wish to Die. 2004). Based on ratings for these factors.

since this was true of total scores for suicidal intent. The results of our study corroborated the studies that found no gender differences in suicidal intent (91/140). some studies have found that actual intent does not vary greatly with age (Haw et al. Evidently. Differences in the mean scores of the following components were statistically significant: Arrangements. 1996). older people have higher scores for suicidal intent (Dyer and Kreitman 1984. Hjelmeland and Hawton 2004). Suicidal intent has also been found in some previous studies to be correlated with age. Circumstances and Alcohol/Drugs. The level of suicidal intent among suicide attempters is relatively easily measurable. despite epidemiological gender differences. such as suicidal intent. people who commit suicide and those who make serious suicide attempts form two overlapping populations that are far more alike than different (Beautrais 2001). It has been argued that male suicide attempts are more likely to be ‘failed’ suicides. One surprising finding was the similarity across age groups of the mean score for the Wish to Die component. The two components characterising preparations before a suicide attempt (Arrangements and Circumstances) showed that older people prepared their suicide attempt more carefully and planned it in greater detail (91/140). 2005). such as a wish to communicate distress and the need for help (Hjelmeland et al. 2003. 46 . 2000). However. Scores for Arrangements and Circumstances rose with age. 2000). that is. it would be plausible to assume that gender may play an important role in other aspects of suicidal behaviour. Based on these differences. as well. Mean scores for Wish to Die showed no age-group differences (90/139). Scores for this component might be expected to rise with age. One study measuring the suicidal intent of people who died by suicide showed no gender differences in scores for suicidal intent. while female suicide attempts may more frequently stem from factors other than a desire to commit suicide. but the level of suicidal intent of persons who have committed suicide remains mostly unknown.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. although men chose more violent methods (Denning et al. Harriss et al. termed in the literature a ‘cry for help’ (Farberow and Shneidman 1961). Analysis of the age variable in the current research showed that suicide attempts are often of a communicative nature. Suicidal behaviour. is frequently a communication act that is not prompted by any real wish to die. 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. 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+). we must accept the fact that. especially with a nonfatal outcome.

According to Kõlves et al (2006). Another component of suicidal intent that was not found to increase with age was Alcohol/Drugs. indeed. be interpreted with care (91-92/140-141). followed by those who used other (hard) methods and self-harm by sharp objects (90/139). or who had no diagnosis. 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). nonetheless. 1993). confirm the role of psychiatric disorders in the suicidal process. Although poisoning has been classified as a ‘soft’ suicide method compared with other methods (Spicer and Miller 2000). Although these patients may lack a strong wish to die.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). the component Alcohol/Drugs does not differentiate between alcohol abusers and nonabusers. duration of hospitalization after the suicide attempt and interviewers’ assessment regarding the physical consequences of and danger to life entailed by the suicide attempt. the following variables were chosen for analysis in Article III: psychiatric disorders and method of attempting suicide (both coded according to the ICD-10). It is known from a previous study that alcohol-dependent suicide attempters obtain relatively low scores on the Suicidal Intent Scale. 47 . 2005) and the results of the present study did. middle-aged men are the highest risk group for alcohol abuse and dependence. Mean scores for suicidal intent were highest among suicide attempters who used poisoning as their method of attempting suicide. Psychiatric disorders have been clearly linked to suicidal behaviour (Joiner et al. Suicide attempters are probably incapable of adequately assessing the potential lethality of the drugs or substances they ingest. in the present study. they are. The role of alcohol or drugs in facilitating suicide attempts was largest among the middle-age groups. while those with an acute stress reaction or other diagnosis. who behave in self-destructive ways without being highly suicidal (Skegg 2005). The lowest level of suicidal intent was found among suicide attempters who used sharp objects for self-harm. had a lower level of suicidal intent. therefore. Self-rated suicidal intent with respect to external characteristics To characterise the severity of attempted suicide separately from self-rated suicidal intent. It must be borne in mind that. and the results should. among suicide victims in Estonia. the suicidal-intent level of suicide attempters using poisoning has been shown to be higher than that of others. at high risk for making fatal suicide attempts (Nielsen et al. These persons are most likely to be ‘habitual self-harmers’. Suicide attempters with serious psychiatric diagnoses (affective disorders or schizophrenia) had significantly higher mean scores for suicidal intent. This was corroborated by the present study (92/141).

There are indicators that 60-70% of patients with acute depression experience suicidal ideas and 10-15% of depressive patients commit suicide (Möller 2003). 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. and danger to life of the suicide attempt (90. with two exceptions only: the correlation between suicidal intent and hopelessness (both multiple-item and oneitem scales) did not reach significance in males or in older adults (40 or more years old) (81/433). All in all. Correlations between different scales were also significant in the analysis by gender and age group. It is very likely that persons committing less severe suicide attempts spend up to two days in hospital. such as the general health and fitness of the suicide attempter and the availability and effectiveness of healthcare services (92/141). but no more. Nevertheless. conclusions about the severity of attempted suicide based on the duration of hospitalization should be drawn carefully since. need for medical attention/treatment. Suicidal intent correlated most strongly with well-being. 2001). depression and hopelessness The results of Article II revealed that suicidal intent was negatively correlated with well-being and positively with depression and hopelessness. Multiple-item and one-item hopelessness scales had similar correlations with other scales. with only minor variations in magnitude of the correlation coefficient. but also depend on broader background factors. the physical consequences are not only the outcome of the current suicide attempt. this does not disparage the interviewers’ entire contribution. the higher the score of depression and hopelessness.92/139. as assessed by all other scales: the lower the well-being. Well-being was correlated negatively with impaired emotional status. in every single case. Associations with well-being. Three days is probably the period needed for stabilization of the suicide attempter’s condition.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). Lower well-being and higher depression or hopelessness indicated more severe suicidal intent. The correlation was the strongest with depression.141). 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- 48 . 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 intent. The finding regarding depression and hopelessness was expected: The severity of the suicide attempt correlated with the level of depression and hopelessness. since there are indications that any question in a Suicidal 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.

1974b). which are not too difficult to answer (Henkel et al. An interesting practical finding of the current study was that the multiple-item and one-item hopelessness scales had similar results. which could be hidden by patients because of the shame and stigma associated with mental disorders (Henkel et al. The strong side of the WHO-5 is its shortness and positive questions. geared towards measuring cheerfulness and the level of energy. 49 . The correlations between the WHO-5 and other scales were all at a significant level. It has been argued that psychometric scales to be used in a daily clinical setting should be simple and brief (Bech et al. Therefore. General statements such as those included 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). The questions of the WHO-5. 1993. 2003. Yip and Cheung 2006) (81/433). along with the already well-known characteristics and risk factors of suicide attempt such as depression and hopelessness. 2005). Dyer and Kreitman 1984). in order to be less stressful for interviewees to answer. 2004) and has been considered a key variable linking depression to suicidal behaviour (Beck et al. 2004a) (82/434). 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. Henkel et al.mon denominator of negative expectations for the future’ (Beck et al. 2001). which confirms previous suggestions that. 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. 2004a). Kuo et al. as these are associated with suicidal behaviour (82/434). 2004b). 1975. Hopelessness is highly associated with depression and suicidal behaviour (Beck et al. the hopelessness scale can be shortened without losing important information (Aish and Wasserman 2001. 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. work in the screening of depression as successfully as questions narrowly oriented towards depressive symptoms. Well-being measured by the WHO well-being index (WHO-5) turned out to be an important issue.

Although scores for the unequivocally expressed Wish to Die component were similar among all age groups. individual-level associations between different dimensions of religiosity – religious denomination. The Alcohol/Drugs component had higher scores among the middle age groups. scores for more equivocal communication components (termed Arrangements and Circumstances) increased with age. The magnitude and causes of the problems vary across the countries included in this study. four components characterising the nuances of the suicidal process before attempted suicide were very clearly differentiated. method of attempting suicide and duration of hospitalization after suicide attempt. subjective religiosity (considering oneself to be a religious person) may serve as a protective factor against non-fatal suicidal behaviour in some cultures. Males and females were also similar with respect to the individual components of suicidal intent. In particular. organisational denomination. Nevertheless. emergency departments of hospitals in both developed and lessdeveloped countries are not currently able to collect this information routinely.CONCLUSIONS The current study focused on attempted suicide as a social phenomenon and revealed the relevance of the sociological as well as epidemiological. Article I showed how suicide attempters were identified in everyday interactions in emergency departments in general hospitals and highlighted that accurate. Level of suicidal intent was associated with psychiatric diagnosis. there were no differences in 50 . In the interviewers’ assessment. Structural and formal religious dimensions seem to be less relevant. 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. 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 departments. According to the results of Article IV. administrative and attitudinal changes. these associations varied between dimensions of religiosity and across cultures. therefore. largely due to cultural and socioeconomic factors. 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. standardized information on the rates and characteristics of medically treated suicide attempts is essential in the development and evaluation of preventative services. However. In the Pierce Suicidal Intent Scale (PSIS) as described in Article III. and subjective religiosity – and attempting suicide exist. The level of suicidal intent was not genderdependent but did increase with age. Rectifying these problems will require substantial legal. failing to collect essential information or to provide follow-up referrals (in some cases because they wish to avoid legal proceedings). clinicians routinely not recording suicide attempts as such and. medical and psychological aspects of attempted suicides.

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. The study left open at least two main directions for future research. in addition to the current research questions. The level of suicidal intent as measured by a self-rated scale expresses the subjective meaning an individual gives to his or her act. depression and hopelessness in suicide attempters.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 WHO-5 is a screening instrument to select vulnerable subjects and further specific suicide risk assessment is mandatory. especially in settings without psychological/psychiatric expertise. should be preferred for preliminary suicide risk assessment. 51 . in understanding the severity of attempted suicide. The main effect does not always necessarily reflect the interplay between these factors in the specific social context. subjective well-being and suicidal intent – in predicting attempted suicide. A low level of subjective psychological well-being is associated with a high level of suicidal intent. First. it would be interesting to study the interaction effects of the three pillars – religiosity. self-rated scales measuring emotional status could serve as useful instruments. Short and positively loaded scales measuring protective factors. such as the WHO-5. It is valuable information on the suicidal person’s true intention and could help clinical observation performed by a specialist in suicide risk assessment. Article II demonstrated that. Second. Subjective psychological well-being has high relevance in the assessment of the severity of attempted suicide. However.

Koostati kvalitatiivsed kirjeldused suitsidaalse käitumise sotsiaalkultuurilise tausta kohta. et sotsiaalne reaalsus luuakse interaktsioonide käigus. Käesoleva dissertatsiooni eesmärk on analüüsida suitsiidikatset kui sotsiaalset nähtust ning on rajatud eeldusele. Colombo (Sri Lanka). Käesolev dissertatsioon on kirjutatud teoreetilises raamistikus. milles kasutatakse selliseid kontseptsioone nagu post-materiaalsed väärtused. mis väidab. igapäevaelu reaalsuse konstrueerimine interaktsioonide käigus (Berger and Luckmann 1966/1991. meditsiiniliste ja psühholoogiliste aspektidega omavad suitsiidikatse kui nähtuse seletamisel olulist tähtsust ka sotsioloogilised aspektid. Käesolev dissertatsioon koosneb neljast artiklist. mis on üksikisiku suhtes väline reaalsus ning mida ei saa seletada üksikisiku tasandi riskiteguritega. mis asetab üksikisiku aktiivse osalejana sotsiaalse reaalsuse keskmesse. et kõrvuti epidemioloogiliste. Osalevad keskused olid valitud Maailma Terviseorganisatsiooni (WHO) ekspertgrupi poolt keskmise ja madala sissetulekuga maadest. Andmete kogumine toimus aastatel 2002 kuni 2004. mis põhinevad samal empiirilisel materjalil ja käsitlevad suitsiidikatse temaatikat pisut erinevatest vaatenurkadest. käitumise subjektiivne tähendus (Weber et al. Tallinn (Eesti) and Yuncheng (Hiina). Empiiriline materjal dissertatsiooni jaoks koguti WHO SUPRE-MISS uuringu käigus. Hanoi (Vietnam).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). 1921/1978. mille eesmärgiks oli suurendada teadmist suitsidaalse käitumise kohta kultuuriliselt erinevates paikades üle maailma. Suitsidaalse käitumise uuringute traditsioon sotsioloogilises võtmes on alguse saanud Durkheimi klassikalisest teooriast (1897/2002). kus suitsiidikatsete kohta on vähem uurimistöid läbi viidud: Campinas (Brasiilia). Durkheimi käsitluse kohaselt on suitsiid kollektiivne sotsiaalne nähtus: sotsiaalne fakt. Sotsioloogilised suitsidaalse käitumise uuringud on keskendunud peamiselt lõpuleviidud suitsiidile ja vähem on teada suitsiidikatsest kui sotsiaalsest nähtusest. eriti ülemaailmses võrdlevas perspektiivis. Struktureeritud näost-näkku intervjuud viidi läbi meditsiinilist abi saanud suitsiidikatse sooritanutega (n = 4314) ja kontrollgrupiga (n = 5484). Nende teooriate ühine tunnusjoon on fenomenoloogiline lähenemisviis. Lisaks on enamik suitsiidikatsete uuringuid viidud läbi arenenud maades ning vähem on teada madala ja keskmise sissetulekuga maade kohta. Spector and Kitsuse 1987. Durban (Lõuna-Aafrika Vabariik). kultuur ja subjektiivne heaolu (Inglehart 1997). Chennai (India). ning tähtsustab üksikisiku poolt oma käitumisele antavat subjektiivset tähendust. Searle 1995). aktiivne mina (Giddens 1991/2004). Enamik hilisematest suitsidaalse käitumise sotsioloogilistest käsitlustest on kas Durkheimi strukturaalse teooria kriitika või selle edasiarendus. Karaj (Iraan). Teoreetiline raamistik loob artiklite vahele silla ja ühendab need sotsioloogilises 52 . Douglas 1967}.

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. Lisaks on dissertatsiooni tulemuste ja diskussiooni esimeses osas antud seni veel avaldamata materjalil baseeruv WHO SUPRE-MISS uuringus osalevate keskuste kvalitatiivne kirjeldus suitsidaalset käitumist mõjutava sotsiaalkultuurilise tausta kohta. Artiklis III iseloomustati suitsiidikatse raskusastet suitsiidikavatsuse skaalal eristuvate faktortunnuste skoori53 . Nende probleemide parandamine eeldab olulisi muudatusi juriidilistes ja administratiivsetes protseduurides ning hoiakutes.võtmes. on väga oluline omada täpset ja standardiseeritud teavet meditsiinilist abi saanud suitsiidikatse sooritanute arvu ja neid iseloomustavate tunnuste kohta. Uuringu tulemused näitasid. seda paljuski kultuurilistest ja sotsiaal-majanduslikest põhjustest tulenevalt: ebatäielik ja ebatäpne erakorralise meditsiini osakonda pöördunud või toodud suitsiidikatse sooritanute registreerimine. kuidas suitsiidikatse sooritanud isikud üldhaiglate erakorralise meditsiini osakondades igapäevaste interaktsioonide käigus identifitseeriti. Kahjuks ei koguta selliseid andmeid rutiinselt peaaegu mitte kusagil maailmas. Artiklis IV uuriti võrdlevas perspektiivis. Need seosed on religioossuse eri dimensioonide ja erinevate kultuuride puhul erinevad. surmaga seotud rituaale ja tseremooniaid ning hoiakuid suitsidaalse käitumise suhtes. organisatsiooniline religioossus) näivad olevat vähem olulised. erakorralise meditsiini osakonnast lahkumine esimesel võimalusel pärast esmaabi saamist selleks. et vältida juriidilist menetlust). Strukturaalsed ja formaalsed religioossuse dimensioonid (religioosne denominatsioon. mille respondendid annavad oma suitsiidikatsele. Probleemid andmete kogumisega olid WHO SUPRE-MISS uuringusse kaasatud maades erinevad. Väga vähesed suitsiidikatse sooritanutest (0-34%) suunati suitsiidikatse järgselt edasi psühhiaatrilise abi saamiseks. Eriti subjektiivne religioossus võib mõnedes kultuurides toimida mitte-fataalse suitsidaalse käitumise vastu kaitsva tegurina. Arvestades vajadust töötada välja ja hinnata efektiivseid ennetustegevusi. Artiklis I on kirjeldatud suitsiidikatse sooritanute peamisi iseloomulikke tunnuseid ning suitsiidikatsete käsitlemise rutiine erinevates keskustes. Artiklid II ja III põhinevad ainult Eesti andmetel ja puudutavad subjektiivset tähendust. et vältida stigmat ehk häbimärgistatust ja mõnedes maades ka juriidilisi sanktsioone. Kirjeldused hõlmavad religioosseid struktuure. meditsiinitöötajate poolne tähelepanematus vigastuse või mürgistuse tekitamise tahtluse osas ning sellest tulenevalt suitsiidikatse sooritanute puudulik edasisuunamine psühhiaatrilise abi saamiseks (mõningatel juhtudel ka selleks. kas religioossus mõõdetuna kolmes erinevas dimensioonis – religioosne denominatsioon. organisatsiooniline religioossus ja subjektiivne religioossus – on suitsiidikatse vastu kaitsvaks teguriks. vigastuse või mürgistuse tegeliku põhjuse tahtlik varjamine patsientide ja nende pereliikmete poolt. Uuringu tulemuste kohaselt on indiviidi-tasandi seosed religioossuse erinevate dimensioonide ja suitsiidikatse sooritamise vahel olemas.

pikemaajalised ettevalmistused. et madal subjektiivne psühholoogiline heaolu on seotud kõrge suitsiidikavatsuse. Subjektiivne psühholoogiline heaolu mõõdetuna WHO-5 skaalal on oluline post-materiaalne väärtus. Tegeliku otsese surmasoovi skooris ei olnud vanuselisi erinevusi. kus puudub psühholoogiline/psühhiaatriline kompetents. depressiooni ja lootusetuse tasemega. et WHO-5 selekteerib küll usaldusväärselt välja haavatavad indiviidid. Suitsiidikavatsuse skaalal eristusid selgelt neli faktorit. kuid edasine põhjalikum suitsiidiriski hindamine on kindlasti vajalik. kuid kaudset kommunikatsiooni väljendavate faktorite skoorid (pikemaajalised ettevalmistused ja vahetud asjaolud) suurenesid vanusega. 54 . Suitsiidikatse raskusaste hinnatuna enesehinnangulise suitsiidikavatsuse skooriga ning intervjueerijate kui välisvaatlejate poolt antud hinnang suitsiidikatse eluohtlikkusele ei langenud kokku. Seega on subjektiivne tähendus. kasutatud suitsiidikatse meetodi ning hospitaliseerimise kestuse vahel. mida teostatakse spetsialisti poolt suitsiidiriski hindamise käigus. Ilmnes.de põhjal ning analüüsiti suitsiidikavatsuse taset soo ja vanuse lõikes ning lähtudes väliselt hinnatavatest tunnustest. eriti asutustes. millel on suur tähtsus suitsiidikatse raskusastme hindamise seisukohalt. vahetud asjaolud ning seos alkoholi/narkootikumidega. mille suitsiidikatse sooritaja oma suitsidaalsele aktile annab. väga oluline informatsioon lisaks välisele hindamisele. Niisugune lühike ja positiivse alatooniga kaitsvaid tegureid mõõtev skaala võiks olla eelistatud esmasel suitsiidiriski hindamisel. Ilmnesid seosed suitsiidikavatsuse raskusastme ning psühhiaatrilise diagnoosi. Emotsionaalset seisundit hinnati depressiooni. lootusetuse ja subjektiivse heaolu skaalade abil. Seos alkoholi/narkootikumidega oli kõrgeima skooriga keskealiste hulgas. Meeste ja naiste vahel faktorite skoorides erinevusi polnud. Siiski tuleb meeles pidada. mis iseloomustavad suitsiidikatsele eelnevat suitsiidiprotsessi: tegelik surmasoov. Artiklis II analüüsiti seoseid suitsiidikavatsuse skaala abil mõõdetud suitsiidikatse raskusastme ning suitsiidikatse sooritanu emotsionaalset seisundit iseloomustavate tunnuste vahel.

(1961). (1979).. Hopelessness. J. De Silva. Phillips. Hopelessness and suicidal behavior. T. R. M. Vijayakumar. D. Bowie. (2003). (2007). L. and Weissman. Botega. J. and Tsuji. and Wasserman. Kjoller. 12(2): 85-91. M. A. Does Beck's Hopelessness Scale really measure several components? Psychological Medicine. J. Journal of Consulting and Clinical Psychology. and ideation in culturally diverse 55 . T. On "intention" in the definition of suicide. P. L. (2001). and Erbaugh. A. Andriessen... Schuyler. Archives of General Psychiatry. Measurement of suicidal behaviour with psychometric scales.. Nakaya. DC: American Association of Suicidology/ Suicide Prevention Resource Center.. S. Awata. A. Lester. A. An overview. Kovacs. J.. Suicidologi. London: Penguin Books. Bech. and Trexler. C. C.). (2006). P. (1974a). Weissman. Lettieri (Eds. Suicide: An unnecessary death. A. International Psychogeriatrics. Kuriyama. 4: 561-571. P. M.. D. (1993). Seki. A. JAMA. Suicides and serious suicide attempts: two populations or one? Psychological Medicine. N. A. (2002). London: Martin Dunitz: 147-157. (1975). H. S.. T. Raabaek Olsen. A. J. K. L. Measuring well-being rather than the absence of distress symptoms: a comparison of the SF-36 Mental Health subscale and the WHO-Five Well-Being Scale. International Journal of Methods in Psychiatric Research. suicidal ideation. Aish. Beautrais. Bech.. A.. Olsen. Bech. and Herman.. A. Ohmori. and Awata. 36(5): 533-538.. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. L. K.). and Fleischmann. The language of suicide. Beck.). H. L. A... M. D. Ward. Steer. Bolhari... N. J. 42(6): 861-865. T. L. depression. Varnik. (1974b). 31(5): 837-845. Tran Thi Thanh. The social construction of reality: a treatise in the sociology of knowledge.. T. Berger. T. Matsuoka... 31(2): 367-372. and Rasmussen.. Suicide and LifeThreatening Behavior. I. Maryland: Charles Press: 45-56. Wasserman (Ed. P. Schlebusch. Beck. D. A. Y. Oxford. Koizumi.. 19(1): 77-88. Beck. F. The measurement of pessimism: the hopelessness scale. N. and Nimeus. Bertolote. plans. Beck. Beck. A. (2005). Core competencies for the assessment and management of individuals at risk for suicide. M. Beck. and clinical diagnosis of depression.. L. D. and Wasserman.. Wasserman and C. Validity and utility of the Japanese version of the WHO-Five Well-Being Index in the context of detecting suicidal ideation in elderly community residents. 234(11): 1146-1149. Bech. 23(2): 139-145.. L. Fleischmann. UK: Oxford University Press: 305-311. S. Psychometric scales in suicide risk assessment. I. R.. 7(2): 6-7. Wasserman (Eds. Beck. D.REFERENCES AAS/SPRC (2006). and Weissman. T. H. Mock. Development of Suicidal Intent Scales. K... A.. T. A global perspective in the epidemiology of suicide. Hozawa. (1966/1991). M. M. A. Suicide attempts.. Mendelson. (2001). D. H. De Leo. and Luckmann. P. Bertolote. Washington. J. T. Journal of Consulting and Clinical Psychology. J. A. (2009). Suicide and LifeThreatening Behavior. P. D. S. The Prediction of Suicide. 47(2): 343-352. Assessment of suicidal intention: the Scale for Suicide Ideation. An inventory for measuring depression. A.. Kovacs. and Newman. A.. M. (2001). Resnick and D. Beck.

Denning. Bray.. Oxford. (2001).. Bertolote. U. Suicide rates.. The American Journal of Psychiatry. (1993). Kienhorst and D. (2009). M. 56 . D. Wasserman (Eds. I. De Leo (Eds.. D. Supplementum.. Psychological Medicine. Suicide and Life-Threatening Behavior. De Leo. London: Martin Dunitz: 3-10. and Martin. (2000). W. Conwell. 38(2): 229-244. 371: 9-20. da Silva. Psychological analysis of the Sri Lankan conflict culture with special reference to the high suicide rate. Dervic. intent. M. Acta Psychiatrica Scandinavica. R. (2006).. 30(3): 282-288. 22(9): 1835-1843.. Suicide in America: A test of Durkheim's theory of religious and family integration. Ellis. Religion and spirituality along the suicidal path. D. Revista Brasileira de Psiquiatria. Religious affiliation and suicide attempt.. life satisfaction and happiness as markers for population mental health. I. (2005). Botega.. (2009). M. H. (2004). de Oliveira.. Bertolote. Suicidal behavior in the community: prevalence and factors associated with suicidal ideation.. K.. (1986). F. K. C. J.. M. M. E. Wasserman and C. D. Breault. (2009). Leiden: Brill: 173-206. Fleischmann. Definitions of Suicidal Behaviour. Bertolote. and MarinLeon. Bonsignore. V. European Archives of Psychiatry and Clinical Neuroscience. G. Kerkhof and A. (2004). R. Validity of the five-item WHO Well-Being Index (WHO-5) in an elderly population. M. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective.. B. Y.sites: the WHO SUPRE-MISS community survey. S. [Factors associated with suicidal ideation in the community: a case-control study]. and Dalgalarrondo. N. Kerkhof. de Azevedo Barros. A global perspective on the magnitude of suicide mortality. D.. Crisis. UK: Oxford University Press: 9198. and Bille-Brahe. Schmidtke (Eds. (2002).). D. King. D. Gulbinat. B. (1995). Oxford.). Bertolote. Suicide and Life-Threatening Behavior. Wasserman (Ed. R. and Heun. D. J. J.. The epidemiology of suicide and parasuicide. J. Burgis. J. Burke. Göttingen: Hogrefe & Huber: 17-41. P. Oquendo. D. De Leo. M. 41(5): 333-337. P. 27(1): 45-53. UK: Oxford University Press: 99104. Bertolote. K. American Journal of Sociology: 628-656. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective.). De Leo.. (2008). and Cox. Diekstra. D. Cadernos de Saúde Pública. Wasserman and C. Wasserman and C. An example of a suicide prevention program in a developing country. and Wasserman. L. D.. B. U. Bille-Brahe. Barkow. (2001). A. S. J.). and Mann. 161(12): 2303-2308. Jessen.). Preventive Strategies on Suicide. N. A. Diekstra. de Oliveira. F. J. Social Psychiatry and Psychiatric Epidemiology. Wasserman (Eds. Marin-Leon. M. 1933-1980. UK: Oxford University Press: 87-90. W. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. J. Suicide in the world: an epidemiological overview 1959-2000. A. 251 Suppl 2: II27-31. (2006). Development of definitions of suicidal behaviours: from suicidal thoughts to completed suicides. Suicidal Behaviour: Theories and Research findings. Suicidal thoughts. D. and gender in completed suicide. K. and Wasserman. de Azevedo Barros. 23(4): 167-170. Botega.. F. B. F. D. Wasserman (Eds. L. J.). Oxford. Grunebaum. 35(10): 1457-1465. W.. J. suicide plans and attempts in the general population on different continents. H. A. F. Suicide: An Unnecessary Death. and Gunnell. Colucci. A. Method choice. R. Bowles. M. Dalgalarrondo. Bolz. G.

Meneghel. J. Fleischmann. J. Bolhari.C. (2004). D. 328(7430): 42-44. D. C. Eddleston.). and Thanh. Subjective well-being. K. A. The British Journal of Psychiatry. (2004). Dyer. R. Victora. and Falk. Giddens. Eddleston. and Lucas. D. QJM: Monthly Journal of the Association of Physicians. Oxford.. Wasserman. C. Conwell. Botega.. G. D. and Kreitman. Psychological Bulletin. M. Religious Homogeneity and Metropolitan Suicide Rates. Self poisoning with pesticides. Sisask. Varnik.J.. H. Schlebusch..).. N. Nguyen. D. Social Forces. Cambridge: Polity. de Carvalho. Diener. Bertolote. (1984). 153: 16-20. (2006). Goldsmith. 95(3): 542-575. Pellmar. A.. Faria. P. M. Psychological Medicine. D. New York: Guilford Press: 325337. (1897/2002). and Phillips. (1967). L. 97(12): 1231-1241.. A. Psychological Medicine. N. J. G. (2004).. M. De Leo. Y. E. E. N. Duberstein. Haviland-Jones (Eds. cultural. and Strock. M. Phillips. Instruments used in SUPRE-MISS. W. Conner... D. Assessing the epidemiology of suicide and parasuicide. Wasserman (Eds. N.. (1997). British Medical Journal. S. E. Modernity and self-identity: self and society in the late modern age. UK: Oxford University Press: 313-316. J. L. L... Flannelly. D. Kleinman. and Caine. Methodologic issues in research on religion and health. W.. Eberly. Cadernos de Saúde Pública. Douglas. A. J. 35(10): 1467-1474. Bulletin of the World Health Organization. and Bunney. Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries. New York: Blakiston Division. D.. and Wasserman. M. T. and McCall. Phillips. D. M. Durkheim. (2009).. Patterns and problems of deliberate self-poisoning in the developing world.. É. E. K. Farberow. Princeton. J.. Subjective Emotional Well-Being. S. E. A. De Silva. Hopelessness... N. 93(11): 715-731. Malakouti. Suicide rates in the State of Rio Grande do Sul. Vijayakumar. R. M. 144: 127-133. The social meanings of suicide. S. M. Ellison.. Suicide: A Study in Sociology. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective.. A. R. D.. C. Fleischmann. and Wasserman. G. Farmer. Bertolote. (2000). K. L..: The National Academies Press. A. R. A. 86(9): 703-709. P. (2002). Bertolote. S. Schlebusch.. A. M. The cry for help. N. N.. S. De Leo. R. M.. V. C. (2005). L. (1984). Ellison. J. (1961). Brazil: association with socioeconomic. (2008). L.. and agricultural factors. 34(7): 1331-1337. K.. E. (1991/2004). M. M. Wasserman and C. 57 .. London and New York: Routledge Classics. L. Botega. The British Journal of Psychiatry. depression and suicidal intent in parasuicide.Diener. Characteristics of attempted suicides seen in emergencycare settings of general hospitals in eight low.: Princeton University Press. T. 76(1): 273-299. J. Washington D. A. Lewis and J. Reducing suicide: A national imperative. (1988). J.and middle-income countries. Evinger. The Southern Medical Journal. J. M. De Silva. and Shneidman. (2000). Burr. J.. T. 22(12): 26112621. Vijayakumar. Poor social integration and suicide: fact or artifact? A case-control study. L. Fleischmann.. De Leo. D. Handbook of emotions..

Heun. Crisis.. R. L. K. Biological Sciences. (2004). Henkel. K. J. 326(7382): 200-201. characteristics of patients with various intentions. Hay. BilleBrahe. R. T. Identifying depression in primary care: a comparison of different methods in a prospective cohort study.. Y. Allgaier. 32(6): 902-909. 17(1): 10-14. V. 182: 537-542.. Maier. 86(2-3): 225-233. A. H... Henkel. Suicidal intent in deliberate self-harm and the risk of suicide: the predictive power of the Suicide Intent Scale. BMJ. Mergl. Hawton. R. V. D. D. 99(3): 171-178.. Mergl. H. Hamdi. J. J. U. Burkart. H. Kohnen. and Hawton. 16(4): 176-181. Acta Psychiatrica Scandinavica. Houston. E. Use of brief depression screening tools in primary care: consideration of heterogeneity in performance in different patient groups. C... Helliwell. D. Kerkhof and A.. Mergl. 145(41): 24-27. Hjelmeland.. Series B.. The social context of well-being. Philosophical Transactions of the Royal Society of London. 26(3): 190-198. F. R. Harriss. Coyne. General Hospital Psychiatry. R.. M. Maier. 5(1): 4-10. E.). and Althaus. U. Internal and external validity of the WHO Well-Being Scale in the elderly general population. Suicide and LifeThreatening Behavior..). Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. C. (2004a). Intentional Aspects of Non-Fatal Suicidal Behaviour. (1999). R. W. The British Journal of Psychiatry. van Heeringen (Eds. (2005). and Hawton. Acta Psychiatrica Scandinavica. Screening for depression in primary care: will one or two items suffice? European Archives of Psychiatry and Clinical Neuroscience. M.. and Hegerl. D. Möller. D.. Correlates of relative lethality and suicidal intent among deliberate self-harm patients. J. De Leo. V.. H. MMW Fortschritte der Medizin. and Eddleston. and Weatherall. J. K. and Townsend. and Mattar. and Hegerl. and Putnam. (2003). Verbally expressed intentions of parasuicide: I. Hawton. Henkel. K.. (1995). Hjelmeland. (2004b). Crisis. Schmidtke (Eds. Scottish Journal of Healthcare Chaplaincy. 58 . Harriss. Hawton and K. L. Practical guideline for dealing with depression]. K. General hospital management of suicide attempters. International Journal of Epidemiology.Gunnell. U. 359(1449): 1435-1446. (2000). K. P. J. D. The international handbook of suicide and attempted suicide. Journal of Affective Disorders. U. F. Clinical correlates of intent in attempted suicide. K. 33(4): 353-364. R.. R. Kohnen. (2005). (2004). Hegerl. D. The British Journal of Psychiatry. 254(4): 215-223. Suicidal Behaviour: Theories and Research Findings. Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Zahl. 186: 60-66. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. W. (2003). 83(5): 406-411. Haw. [From patient screening to management list in suicide risk. and Hegerl.. Verbally expressed intentions of parasuicide: II. Hawton. K. Amin. New York: Wiley. Hawton. Möller. H. Hjelmeland. and Zahl. H. Möller. (2003). (2003). Cambridge/Göttingen: Hogrefe & Huber Publishers: 67-78. (2002). R. (1996). Kohnen. The spirituality of adults in Britain – recent research. Prediction of fatal and nonfatal repetition. (2003). and Bech. (1991). K. U.

Kreitman.J. Bille-Brahe (Ed. and Wingate. Platt. Brown. 30(4): 295-303. 359(1449): 1331-1332. (1998). substance disorder. Hulten. and Schmidtke. G.. F. (2000). Conceptual confusion about intentions and motives of nonfatal suicidal behavior: A discussion of terms employed in the literature of suicidology. 2010 from http://www. H. U. Kerkhof. U. economic. J. Series B. Bille-Brahe. (2000). 359(1449): 1447-1451. V. and Eaton. Jiang. depression. M. and political change in 43 societies. A. E.: Princeton University Press. Annual Review of Psychology. Baylis... Michel. J. M. European Child & Adolescent Psychiatry. Biological Sciences. H. and Nordvik. Hjelmeland.... Williamson. (1977). Philip..... Joiner. Wasserman. and Larson. S. H. Hjelmeland. K. Corcoran. 21(1): 31-35. H. B. F. E. K. Kelleher. and Keeley. (1999b). Renberg.. A.. N.. N. B. General health and well-being in outpatients with depressive and bipolar disorders. and Querejeta. A. H.. Retrieved March 12. H. V. H. H. Nordvik. McCullough. S. and Keverne. (2001).. Huppert. (2000). (2005). F. W. J. Koenig. Bille-Brahe. Archives of Suicide Research. neurobiology and social science. L. Chambers. Schmidtke. (2002). (2004). H.. and Bagley. West Conshohocken: Templeton Foundation Press. Copenhagen: WHO Regional Office for Europe. M. The communicative aspect of nonfatal suicidal behavior . Recommended care for young people (15-19 years) after suicide attempts in certain European countries. (1997). S.who. (2004). 60(2): 150-156. Series B. W. and Baylis. Huppert. N. L. The pattern of suicide in Pakistan. Schmidtke.. M. B. D.. A. T.. Hawton. 56: 287-314. A. J. Nordic Journal of Psychiatry.. Crisis. Michel. A. Inglehart. De Leo. 23(4): 144-155. Bjerke. Kuo..are there gender differences? Crisis. Knizek. and Knizek. 5: 275-281. ICD-10 (1990/2007). Hjelmeland. International Classification of Diseases.. K. Archives of Suicide Research. and suicidality--a 13-year community-based study.. P. Lonnqvist. W. Princeton. H. R. 10th Revision (ICD-10). London: John Wiley. Religious sanctions and rates of suicide worldwide. U. and Reza. Bernasco. J. 59 . Handbook of Religion and Health. B. G. R. D. 19(2): 78-86. L. Well-being: towards an integration of psychology. Kerkhkof.. (2004).. Parasuicide. Suicide and LifeThreatening Behavior. P. A crosscultural study of suicide intent in parasuicide patients. Parasuicide. 5(4): 277-283.. (2005). I. Koenig. C. H. M. A.Hjelmeland. T. (1999a). X. E. H. The British Journal of Psychiatry. Philosophical Transactions of the Royal Society of London. Faith And Mental Health: Religious Resources for Healing. N. D. 39(6): 497-501. and Bech. Introduction: why do we need a science of well-being? Philosophical Transactions of the Royal Society of London. Bille-Brahe. (1969). 115(523): 746-747. Khan. (1999)..int/classifications/apps/icd/icd10online/. Gallo. E.. Kreitman. F.. Salander-Renberg. E. New York: Oxford University Press. A. E. Conceptual confusion about intentions and motives of nonfatal suicidal behaviour: A discussion of terms employed in the literature of suicidology. Social Psychiatry and Psychiatric Epidemiology. L. R. European Parasuicide Study Interview Schedule (EPSIS).. D. Greer. W. N.. D. Modernization and postmodernization: cultural. B. 9(2): 100-108. and Knizek.. and Wasserman. J. Biological Sciences. Kessing. U. Hopelessness.). S. L. The psychology and neurobiology of suicidal behavior. S. Kerkhof. Hansen. Facts and Figures: WHO/EURO. (2006). Crisis. G. J. A. Jr.

Suicide attempters in a general hospital unit in India: their socio-demographic and clinical profile-emphasis on crosscultural aspects. Wasserman and C.. K.. (2009). J. Buchholz. D. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses. S. and Koenig. U. Marusic. Journal of Health and Social Behavior. V. D. Suicide and Life-Threatening Behavior. D.. Davidson. Y. Gräfe. R. (2006). Lyons.. A. Keeley. Musick. L. J.. Mitchell. A. M. Witte. S. and Williams. A. and D'Souza..Kõlves. (2000).. P. Suicide and Islam. S. (1994). Spitzer. Pathways to suicide: A survey of self-destructive behaviors. 94(1): 26-30. (2001). UK: Oxford University Press: 123-126. D. Understanding deliberate self-harm: the patients' views. S. Psychological Medicine. B.. Mittendorfer Rutz. (2005). 36(7): 923-930. Kerkhof and A. (2004). Baltimore. K. Mann. C. 23(4): 251-255. Zipfel. Silverman. Tyrer. H.. Tooding. K. Maris. 294(16): 2064-2074. D. Takahashi. (2007). Beautrais. Cambridge/Göttingen: Hogrefe & Huber: 125-137.. Apter. Schmidtke (Eds. M... E. Haas. Löwe.. and Bongar. Lester.. J. Bhat.. Patton.. Motives and suicide intent underlying hospital treated deliberate self-harm and their association with repetition. W. and Smith. K.. Lagerspetz. Crisis. 78(2): 131-140. M. 10(1): 77-97. H. McAuliffe. A. Varnik. M. Z. and Herzog.. Latha. Valach.. R. Oxford. L. The British Journal of Clinical Psychology. Price. Suicide risk assessment: a review of procedures.. P. B. and Hendin. P. A.. Moreira-Almeida. P. W. C. P. Wasserman (Eds. Mehlum. Revista Brasileira de Psiquiatria. New York: Guilford Press. C. Journal of Affective Disorders.. D. Löhr. and Wasserman. Attendance at religious services and mortality in a national sample. S. F. A. Hegerl. Phillips.. Nonfatal suicidal behavior as a communication. Quenter. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective... (1996). J. S. (2006). Suicidal Behaviour: Theories and Research Findings. (1981).). House. Schmidtke. 8(3): 178-186. K. P. Värnik. A. M.. A. M. (2000). H. Rutz. A. Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff. Silverman... L. 60 .. (2005). Wasserman. Currier. Marital relations of suicide attempters. R. Maris. D. Neto. (1996). A. Accident and Emergency Nursing. C.). JAMA. and Schmidtke.. Bille-Brahe. D. L. Crisis. W. MD: John Hopkins University Press. Suicide prevention strategies: a systematic review. P. M. 45(2): 198213. (2004). K. W. Acta Psychiatrica Scandinavica. (2006). G. 37(4): 397-408. U. 44(Pt 4): 495-504.. De Leo. A. S. Rihmer. 28(3): 242-250.. Suicide attempts in Europe.. K. Constructing post-communism: a study in the Estonian social problems discourse.. and Dennis. Lonnqvist. 22(2): 49-51.. Archives of Suicide Research. M. The role of alcohol in suicide: a case-control psychological autopsy study. M. Arensman. A. Emergency Medicine Journal. K.. Bertolote.. A. Schmidt. Religiousness and mental health: a review. Shaffer. D. and Schmidtke. (2006). M. Embling. Corcoran. L. and Fitzgerald. U.. G. Michel. A. and Waeber.. Kroenke. Berman. E. A.. Lester. Malone. Yip. A. A. J. Hopelessness and positive and negative future thinking in parasuicide. L. (2004). R.. and Thompson.. Turku: Turun Yliopisto.. MacLeod. S. J. C.. Comprehensive textbook of suicidology. Tata. 15(4): 172-178..

Mäkinen, I. H. (1997). On Suicide in European Countries. Some Theoretical, Legal and Historical Views on Suicide Mortality and Its Concomitants. Stockholm: Stockholm University. Mäkinen, I. H. (2009). Social theories of suicide. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. D. Wasserman and C. Wasserman (Eds.). Oxford, UK: Oxford University Press: 139-147. Möller, H. J. (2003). Suicide, suicidality and suicide prevention in affective disorders. Acta Psychiatrica Scandinavica. Supplementum, 418: 73-80. National Strategy for Suicide Prevention (2001). Goals and Objective for Action. Rockville, MD: US Department of Health and Human Services, Public Health Service. Neeleman, J. (1998). Regional suicide rates in the Netherlands: does religion still play a role? International Journal of Epidemiology, 27(3): 466-472. Neeleman, J., de Graaf, R. and Vollebergh, W. (2004). The suicidal process; prospective comparison between early and later stages. Journal of Affective Disorders, 82(1): 43-52. Nielsen, A. S., Stenager, E. and Brahe, U. B. (1993). Attempted suicide, suicidal intent, and alcohol. Crisis, 14(1): 32-38. Niméus, A., Alsén, M. and Träskman-Bendz, L. (2002). High suicidal intent scores indicate future suicide. Archives of Suicide Research, 6(3): 211-219. Nisbet, P. A., Duberstein, P. R., Conwell, Y. and Seidlitz, L. (2000). The effect of participation in religious activities on suicide versus natural death in adults 50 and older. The Journal of Nervous and Mental Disease, 188(8): 543-546. Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., Bruffaerts, R., Chiu, W. T., de Girolamo, G., Gluzman, S., de Graaf, R., Gureje, O., Haro, J. M., Huang, Y., Karam, E., Kessler, R. C., Lepine, J. P., Levinson, D., Medina-Mora, M. E., Ono, Y., Posada-Villa, J. and Williams, D. (2008). Crossnational prevalence and risk factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry, 192(2): 98-105. O'Caroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L. and Silverman, M. M. (1996). Beyond the Tower of Babel: a nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26(3): 237-252. Parsons, T. (1937/1968). The structure of social action: a study in social theory with special reference to a group of recent European writers. New York: Free Press. Pescosolido, B. A. and Georgianna, S. (1989). Durkheim, suicide, and religion: toward a network theory of suicide. American Sociological Review, 54(1): 33-48. Phillips, M. R., Li, X. and Zhang, Y. (2002a). Suicide rates in China, 1995-99. Lancet, 359(9309): 835-840. Phillips, M. R., Yang, G., Zhang, Y., Wang, L., Ji, H. and Zhou, M. (2002b). Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet, 360(9347): 1728-1736. Pierce, D. W. (1977). Suicidal intent in self-injury. The British Journal of Psychiatry, 130: 377-385. Platt, S., Bille-Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T., Crepet, P., De Leo, D., Haring, C., Lonnqvist, J., Michel, K. and et al. (1992). Parasuicide in Europe: the WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatrica Scandinavica, 85(2): 97-104. Primack, B. A. (2003). The WHO-5 Wellbeing Index performed the best in screening for depression in primary care. ACP Journal Club, 139(2): 48.

61

Roberts, D. M., Karunarathna, A., Buckley, N. A., Manuweera, G., Sheriff, M. H. and Eddleston, M. (2003). Influence of pesticide regulation on acute poisoning deaths in Sri Lanka. Bulletin of the World Health Organization, 81(11): 789-798. Runeson, B. S., Beskow, J. and Waern, M. (1996). The suicidal process in suicides among young people. Acta Psychiatrica Scandinavica, 93(1): 35-42. Ryan, R. M. and Deci, E. L. (2001). On happiness and human potentials: a review of research on hedonic and eudaimonic well-being. Annual Review of Psychology, 52: 141-166. Ryan, R. M., Huta, V. and Deci, E. L. (2008). Living well: A self-determination theory perspective on eudaimonia. Journal of Happiness Studies, 9(1): 139-170. Schmidtke, A., Bille-Brahe, U., DeLeo, D., Kerkhof, A., Bjerke, T., Crepet, P., Haring, C., Hawton, K., Lonnqvist, J., Michel, K., Pommereau, X., Querejeta, I., Phillipe, I., Salander-Renberg, E., Temesvary, B., Wasserman, D., Fricke, S., Weinacker, B. and Sampaio-Faria, J. G. (1996). Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica, 93(5): 327-338. Schmidtke, A., Weinacker, B., Löhr, C., Bille-Brahe, U., De Leo, D., Kerkhof, A., Apter, A., Batt, A., Crepet, P., Fekete, S., Grad, O., Haring, C., Hawton, K., van Heeringen, C., Hjelmeland, H., Kelleher, M., Lönnquist, J., Michel, K., Pommerau, X., Querejeta, I., Philippe, A., Salander Renberg, E., Sayil, I., Temesvary, B., Värnik, A., Wasserman, D. and Rutz, W. (2004). Suicide and Suicide Attempts in Europe. Suicidal Behaviour in Europe: Results from the WHO/Euro Multicentre Study on Suicidal Behaviour. A. Schmidtke, U. Bille-Brahe, D. De Leo and A. Kerkhof (Eds.). Cambridge/Göttingen: Hogrefe & Huber: 15-28. Searle, J. R. (1995). The construction of social reality. London: Penguin Books. Siegrist, M. (1996). Church attendance, denomination, and suicide ideology. The Journal of Social Psychology, 136(5): 559-566. Silverman, M. M. (2006a). In this Issue. Suicide and Life-Threatening Behavior, 36(6): iii. Silverman, M. M. (2006b). The Language of Suicidology. Suicide and Life-Threatening Behavior, 36(5): 519-532. Silverman, M. M., Berman, A. L., Sanddal, N. D., O'Carroll P, W. and Joiner, T. E. (2007a). Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Background, rationale, and methodology. Suicide and Life-Threatening Behavior, 37(3): 248-263. Silverman, M. M., Berman, A. L., Sanddal, N. D., O'Carroll P, W. and Joiner, T. E. (2007b). Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 2: Suicide-related ideations, communications, and behaviors. Suicide and Life-Threatening Behavior, 37(3): 264-277. Simpson, M. E. and Conklin, G. H. (1988). Socioeconomic Development, Suicide and Religion: A Test of Durkheim's Theory of Religion and Suicide. Social Forces, 67(4): 945-964. Skegg, K. (2005). Self-harm. Lancet, 366(9495): 1471-1483. Spector, M. and Kitsuse, J. I. (1987). Constructing social problems. New York: Aldine de Gruyter. Spicer, R. S. and Miller, T. R. (2000). Suicide acts in 8 states: incidence and case fatality rates by demographics and method. American Journal of Public Health, 90(12): 1885-1891.

62

Stack, S. (1983). The effect of religious commitment on suicide: a cross-national analysis. Journal of Health and Social Behavior, 24(4): 362-374. Stack, S. (2000). Suicide: a 15-year review of the sociological literature. Part II: modernization and social integration perspectives. Suicide and Life-Threatening Behavior, 30(2): 163-176. Stack, S. and Kposowa, A. J. (2008). The Association of Suicide Rates with IndividualLevel Suicide Attitudes: A Cross-National Analysis. Social Science Quarterly, 89(1): 39-59. Stack, S. and Lester, D. (1991). The effect of religion on suicide ideation. Social Psychiatry and Psychiatric Epidemiology, 26(4): 168-170. Stengel, E. (1962). Recent research into suicide and attempted suicide. The American Journal of Psychiatry, 118: 725-727. Stengel, E. (1964). Suicide and attempted suicide. Baltimore: Penguin. Suominen, K., Isometsa, E., Ostamo, A. and Lonnqvist, J. (2004). Level of suicidal intent predicts overall mortality and suicide after attempted suicide: a 12-year follow-up study. BMC Psychiatry, 4: 11. Thanh, H. T., Jiang, G. X., Van, T. N., Minh, D. P., Rosling, H. and Wasserman, D. (2005). Attempted suicide in Hanoi, Vietnam. Social Psychiatry and Psychiatric Epidemiology, 40(1): 64-71. Tooding, L. M., Värnik, A. and Wasserman, D. (2004). Gender and age-specific dynamics of suicides in the Baltic states during the transition period. Trames, 8: 299-308. Tousignant, M., Seshadri, S. and Raj, A. (1998). Gender and suicide in India: a multiperspective approach. Suicide and Life-Threatening Behavior, 28(1): 50-61. Townsend, E. (2007). Suicide Terrorists: Are They Suicidal? Suicide and Life-Threatening Behavior, 37(1): 35-49. Wassenaar, D. R., van der Veen, M. B. W. and Pillay, A. L. (1998). Women in cultural transition: suicidal behavior in South African Indian women. Suicide and LifeThreatening Behavior, 28(1): 82-93. Wasserman, D. (2001a). Affective disorders and suicide. Suicide: An unnecessary death. D. Wasserman (Ed.). London: Martin Dunitz: 39-47. Wasserman, D. (2001b). A stress-vulnerability model and the development of the suicidal process. Suicide: An unnecessary death. D. Wasserman (Ed.). London: Martin Dunitz: 13-27. Wasserman, D., Dankowicz, M., Värnik, A. and Olsson, L. (1997). Suicide trends in Europe, 1984-1990. Suicide: Biopsychosocial Approaches. A. J. Botsis, C. R. Soldatos and C. N. Stefanis (Eds.). Amsterdam: Elsevier: 3-10. Wasserman, D. and Wasserman, C. (2009). Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford, UK: Oxford University Press. Wasserman, D. and Värnik, A. (1994). Increase in suicide among men in the Baltic countries. Lancet, 343(8911): 1504-1505. Wasserman, D. and Värnik, A. (2001). Perestroika in the former USSR: history's most effective suicide preventive programme for men. Suicide: An unnecessary death. D. Wasserman (Ed.). London: Martin Dunitz: 253-258. Wasserman, D., Värnik, A. and Dankowicz, M. (1998). Regional differences in the distribution of suicide in the former Soviet Union during perestroika, 1984-1990. Acta Psychiatrica Scandinavica. Supplementum, 394: 5-12. Watson, D., Goldney, R., Fisher, L. and Merritt, M. (2001). The measurement of suicidal ideation. Crisis, 22(1): 12-14.

63

. A. E. Geneva: World Health Organization. Economy and society: an outline of interpretive sociology. M. Vijayakumar (Ed. G. Värnik. and Wasserman. S. Oxford. C. Y. (1998). Wasserman (Eds. A. 7: 51-59. and Wittich. (2009).).).. and Wasserman.. Fredriksborg: World Health Organization. L. 26(3): 112-119. Suicide Trends in the Baltic States. Sisask. and Eklund.. Värnik. Suicide in developing countries (2): risk factors. A. Wasserman. Oxford Textbook of Suicidology and Suicide Prevention. Värnik. Dankowicz. Suicide Prevention in Estonia. (2010).. D. 64 . 4: 79-90. (2005). 2010 from http://data. and Wasserman. D.). Info Package: Mastering Depression in Primary Care. M. Värnik. (2003). Trames. L. Värnik. M. Värnik. A. L. L. D. 394: 13-19. (2005). John. 38(4): 395-403. P. J. L. Nemtsov. Eesti sotsiaalne julgeolek ja rahva turvalisus.. Health and Quality of Life Outcomes. G. Palo. Suicide during transition in the former Soviet Republics. J. Marked decrease in suicide among men and women in the former USSR during perestroika.. WHO/Euro MDB (2010). A. D. India: Orient Longman: 149-162. Värnik. Raska and T. D. Eesti edu hind. L. Massive increase in injury deaths of undetermined intent in ex-USSR Baltic and Slavic countries: Hidden suicides? Scandinavian Journal of Public Health... Suicide and Homicide: Durkheim's and Henry & Short Theories Tested on Data from the Baltic States. K. Suicide in the former republics of the USSR. Crisis. Archives of Suicide Research.int/hfamdb/. UK: Oxford University Press: 191-199. A.Weber. (2003). Pirkis. Roth.who. Yip. Vijayakumar. Värnik. Wasserman (Eds. WHO Regional Office for Europe. European Mortality Database (MDB). Acta Psychiatrica Scandinavica.euro. and Wasserman. Raitviir (Eds. D. 29: 150-162. Quick assessment of hopelessness: a cross-sectional study. D. WHO (2002). A.. (1998). Yur'yev. A. (2009).. and Pollock. Psychiatria Fennica. M. G. B. 1970-1997. Leppik. Tooding. WHO (1998). Wasserman and C. Psychosocial risk factors for suicide in India. P. H. Kõlves. A. M. Berkeley: University of California Press. and Cheung.. Wasserman and C. and Mokhovikov. Multisite Intervention Study on Suicidal Behaviours SUPRE-MISS: Protocol of SUPRE-MISS. (2006). E. E. Psychiatric Research Unit. Williams. Suicide Prevention: Meeting the Challenge Together. (2000). Värnik. Palo. Suitsiid on rahva vaimujõu peegel [Suicide as a mirror of society's mental health]. 4: 13.. M. Retrieved January. Supplementum. A. The psychology of suicidal behaviour. and Whiteford. Oxford Textbook of Suicidology and Suicide Prevention. (1921/1978). UK: Oxford University Press: 791-792. L. UK: Willey. R. S. Vijayakumar. Chicester. Tallinn: Eesti Entsüklopeediakirjastus: 130-136.). Oxford.. Tooding. (2000). A. Regional Office for Europe..

PUBLICATIONS   49 65 .

.

I .

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

Brisbane. in Colombo (43.6% females). Mental Health Research Centre.8 % females).5 % males). Campinas. V A N T U O N G N G U Y E N 1 0 A N D D A N U T A W A S S E R M A N 1 1 2 1 Department of Mental Health and Substance Abuse. Subjects seen for suicide attempts. The objective was to describe patients presenting themselves at emergency-care settings following a suicide attempt in eight culturally different sites [Campinas (Brazil). (China)]. Chennai. Brazil . Nelson R. 61. Viet Nam . South Africa . Tehran. Queensland. 6 Department of Psychiatry. Department of Mental Health and Substance Abuse. such as health. medicaments. 5 Estonian-Swedish Mental Health and Suicidology Institute. Durban. 11 National and Stockholm County Centre for Suicide Research and Prevention of Mental Ill-Health (NASP). Durban (South Africa). Geneva. Faculty of Medicine. Switzerland.and middle-income countries ´ A L E X A N D R A F L E I S C H M A N N 1 . World Health Organization. namely selfpoisoning. D A M A N I D E S I L V A 9. Geneva 27. (Email : bertolotej@who. N E U R Y B O T E G A 3. Faculty of Health Sciences. M E R I K E S I S A S K 5. Sri Lanka. Kotturpuram.Psychological Medicine. Estonia . 23. 9 Department of Psychological Medicine. 4 Beijing Suicide Research and Prevention Center. and Yuncheng. agriculture. 19. Self-poisoning was the main method of attempting suicide in all eight sites. 2005. 7 Tehran Psychiatric Institute.1017/S0033291705005416 Printed in the United Kingdom Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low. Karaj (Iran). Mandela School of Medicine. World Health Organization.2% males. and in Chennai (33. In four of the eight sites less than one-third of subjects received any type of referral for follow-up evaluation or care. Beijing. Sweden ABSTRACT Background. ´ * Address for correspondence : Dr Jose M. f 2005 Cambridge University Press doi:10. 10 Hanoi Medical University. Regulations for the access to drugs. Results. India . Estonian Center of Behavioral and Health Sciences. Australian Institute for Suicide Research and Prevention. CH-1211. education. School of Family and Public Health Medicine. pesticides. FCM – UNICAMP. Tallinn. 1467–1474. D I E G O D E L E O 2 . Beijing Hui Long Guan Hospital. 3 Department of Psychiatry. Colombo (Sri Lanka). People’s Republic of China . M I C H A E L P H I L L I P S 4. Chennai (India). Australia . and other toxic substances need to be improved and revised regulations must be implemented by integrating the efforts of different sectors. University of Colombo.8 % males. L O U R E N S S C H L E B U S C H 8. and justice. Method. Bertolote. University of KwaZulu–Natal. Switzerland . The suicide attempt resulted in danger to life in the majority of patients in Yuncheng and in Chennai (over 65%). 35. K A Z E M M A L A K O U T I 7. Hanoi. as identified by the medical staff in the emergency units of 18 collaborating hospitals were asked to participate in a 45-minute structured interview administered by trained health personnel after the patient was medically stable. Stockholm. Department of Public Health Sciences. Voluntary Health Services & SNEHA. The care of patients who attempt suicide needs to include routine psychiatric and psychosocial assessment and systematic referral to professional services after discharge. Conclusions. B E R T O L O T E 1*. Tallinn (Estonia). Griffith University. Islamic Republic of Iran . 8 Department of Behavioural Medicine. Karolinska Institute and Swedish National Institute of Psychosocial Medicine. Hanoi (Viet Nam). Action for the prevention of suicide attempts can be started immediately in the sites investigated by addressing the one most important method of attempted suicide. Self-poisoning by pesticides played a particularly important role in Yuncheng (71.6 % females.int) 1467 69 . J O S E M. L A K S H M I V I J A Y A K U M A R 6.

suicide attempts are one of the main reasons for hospital emergency treatment of young people. Those who agreed. A total of 4314 subjects were included. Universidade Estadual de Campinas. it was Hospital das Clinicas. In Colombo (Sri Lanka). In 2000. in all age groups. psychologists and. the Government Royapettah Hospital. Schmidtke et al. SUPRE-MISS has three components : (i) a randomized clinical trial to evaluate treatment strategies for suicide attempters resuscitated in emergency settings in defined catchment areas . King Edward VIII. monitored attempted suicides treated at 25 health facilities in 19 European countries. and Thanh Nhan hospitals participated. RK Khan. This paper describes the characteristics of the suicide attempters of the intake component (i). and (iii) a qualitative community description of the basic socio-cultural characteristics of the target communities. However. no official or systematically collected statistics on suicide attempts exist on a national basis. (ii) a community survey to identify suicidal ideation and behaviour in the same catchment areas . In Durban (South Africa).1468 A. The majority of these participated in the randomized clinical controlled trial. putting a heavy burden on health-care systems. Ghaem and Rajaee hospitals were involved. Madani. psychiatric nurses were trained to administer the intake 70 . Interviewing At each site 2–12 psychiatrists. including suicide mortality. In many countries. particularly among younger age groups. 2004) between 1989 and 1992. Saint Pault. Suicide occurs in both developed and developing countries. These hospitals served the respective catchment area of the participating sites which were mostly urban. Depending on the location. it was the Yuncheng County Hospital. the information thus obtained cannot be construed as representing the respective ‘ national reality ’. In Tallinn (Estonia). the Bach Mai. where suicide is among the five leading causes of death for both sexes. but also a major public health problem. the Addington. For the past few decades the global picture has been one of rising trends. the Emam. the WHO launched the multisite intervention study on suicidal behaviours (SUPRE-MISS) which aimed to increase knowledge about suicidal behaviours and about the effectiveness of interventions for suicide attempters in culturally diverse places around the world. Whereas many WHO Member States report on mortality. sex and site is given in Table 1. filled in a consent form and were administered the detailed intake interview. 1996). In 2002. it was estimated that 877 000 lives were lost due to suicide (WHO. The WHO/EURO multicentre study on suicidal behaviour. Subjects All suicide attempters identified between January 2002 and January 2004 (in Hanoi up to April 2004) in emergency-care settings by medical staff within a catchment area with a population of at least 250 000 in eight countries were invited to participate in the study. Fleischmann et al. In Karaj (The Islamic Republic of Iran). 1992 . 1996 . and together they form a pool from which many future suicides emerge (United Nations Department for Policy Coordination and Sustainable Development. Dong Da. In Yuncheng (People’s Republic of China). suicide attempts can be up to 10–40 times more frequent than completed suicides (Schmidtke et al. In Campinas (Brazil). 2003). the North Estonian Regional Hospital (the Tallinn Mustamae Hospital and the Tallinn Psychiatric Clinic) participated. The majority of individuals who attempt suicide tend to be adolescents and young adults. the acute care wards of the National Hospital Sri Lanka. ´ Hulten et al. except for Yuncheng which was rural. including Israel and Turkey (Platt et al. 2000). In Chennai (India). medical doctors. METHOD The emergency-care departments The study was carried out in one or more emergency-care departments of the participating sites. Their distribution by age. in one instance. In Hanoi (Viet Nam). INTRODUCTION Suicide is not only a global and personal tragedy. and Prince Mshiyeni Memorial hospitals were involved in the study.

Sex and age of suicide attempters at emergency care departments of SUPRE-MISS sites Campinas (n=162) M F 64 30 Chennai (n=680) M 49 25 F 51 22 Colombo (n=1067) M 44 25 F 56 22 Durban (n=570) M 27 26 F 71 21 Hanoi (n=301) M 29 24 F 71 23 Karaj (n=945) M 42 23 F 58 22 Tallinn (n=469) M 34 29 F 66 30 Yuncheng (n=120) M 33 33 F 68 30 Sex (%. However. Durban (n=570) and Colombo (n=1067) almost all subjects completed the intake interview. the total number of suicide attempters seen at the emergency-care department was not known. The interviews were conducted faceto-face and took place at the emergency-care departments. the majority of those not interviewed precipitously left the emergency-care department before the researchers arrived to conduct the interview. In Karaj (n=945) and Hanoi (n=301) all suicide attempters identified in the emergencycare departments over the specified period participated in the intake evaluation. in Tallinn 469 out of 884 (53 %) and in Yuncheng 120 out of 194 (62 %) suicide attempters seen in the emergency-care departments participated in the intake interview. but the number of suicide attempts that were not seen at the acute care wards was unknown. only sex and age are known . It covered a detailed intake part comprising the method of the suicide attempt. Given the nature of these reasons. to enrol them eventually and. based on the European Parasuicide Study Interview Schedule (EPSIS). RESULTS The intake of subjects An attempt was made to include all suicide attempters seen at the emergency-care departments. In Chennai 680 out of 1691 (40 %). in Colombo almost all selfpoisoning and surgically serious self-injury patients who were admitted participated in the intake evaluation. it is impossible to both estimate the number of these ‘ losses’ and identify means of avoiding them. Of those who did not participate.2 % (Durban). F. in some instances. two in Durban) indicated themselves to be transsexual. Overall. Instrument The questionnaire. more female than male suicide attempters presented themselves at the emergency-care departments ranging from 51. Three persons (one in Campinas. Male . as well as sociodemographic information. However. 1999). A series of other variables was also answered.Suicide attempts in developing countries’ emergency care 1469 Table 1.3 % (Chennai) to 71. intentional misreporting of suicides as accidental by patients and family members. Also. In Campinas (n=162). 2002a). and rapid departure from the emergency rooms of patients (before the research staff could arrive) made it difficult to include all eligible patients in the intake. of the WHO/EURO multicentre study on suicidal behaviour was translated and pilot-tested in each country. rounded) Age (years) (median) 35 29 M. because it was suspected that a small (unknown) number of cases was not notified by the emergency departments to the researchers : the subjects could have been admitted directly to a psychiatric unit without being treated in the emergency department or the subjects might have left before the research team could meet them. the type of care and referral as determined by the medical staff. Sociodemographic characteristics In all sites. (Kerkhof et al. The median age among females ranged from 21 years (Durban) to 30 71 . inadequate recording of emergency room visits. even to make an accurate assessment of the total number of suicide attempters coming to the emergency-care units. failure of the emergency room staff to notify research staff. at most 3 days after the emergency room admission. the results of which are not reported here (WHO. female. interview. the patients were young. Suicide attempters were identified by the medical staff in the emergency rooms and interviewed once medically stable. physical consequences.

The one exception was in Tallinn. except for Campinas. In most cases self-poisoning involved the ingestion of pesticides or medications.7 % of the suicide attempters combined self-poisoning by alcohol with another method. Fleischmann et al. was rarely applied. i.0 % males. (n=57) 28 51 21 (n=57) 11 47 25 14 4 (n=52) 58 25 0 0 10 (n=103) 35 41 24 (n=104) 14 39 20 26 1 (n=90) 33 23 8 12 16 (n=331) 50 47 3 (n=330) 9 28 48 16 0 (n=323) 79 10 6 0 2 (n=349) 40 54 6 (n=349) 19 24 43 14 0 (n=308) 50 4 7 35 0 (n=465) 59 38 2 (n=438) 4 15 79 1 0 (n=446) 67 12 9 0 12 (n=589) 57 42 2 (n=569) 4 9 83 4 0 (n=551) 38 11 18 26 3 (n=400) 68 24 8 (n=401) 2 29 61 7 2 (n=370) 25 29 34 7 4 F (n=87) 70 28 2 (n=53) 0 4 21 64 11 (n=64) 38 14 27 2 8 M (n=211) 59 39 2 (n=167) 1 1 15 61 22 (n=170) 32 9 29 8 7 F (n=395) 67 31 2 (n=396) 2 13 33 53 0 (n=393) 23 26 13 2 34 M (n=548) 41 56 3 (n=549) 4 10 23 63 0 (n=548) 4 1 20 68 7 F (n=161) 47 39 14 (n=161) 4 24 32 38 2 (n=161) 54 18 8 0 19 M (n=308) 33 46 21 (n=308) 5 24 33 36 2 (n=308) 51 12 17 4 14 F (n=39) 23 69 8 (n=39) 15 31 49 5 0 (n=39) 85 3 8 0 3 M (n=81) 16 82 2 (n=81) 28 47 24 1 0 (n=81) 83 1 3 4 7 F .1470 A. 14. except for Campinas. it was also an important method in Campinas and Hanoi. More than one method. In six of the eight countries male attempters were more likely to be single than married. With the exception of Yuncheng (where men had a higher educational attainment than women) the educational achievement of male and female suicide attempters was similar (Table 2). ‘housekeeper ’ and ‘full-time student’ (Table 2). where 10. In all sites. In all sites. Yuncheng Tallinn Karaj Hanoi Durban M Colombo F M F Chennai M Campinas F M 72 Marital status Single Married Separateda Education None Primary Secondary Higher Other Employment Full/part-time Unemployed Student Housekeeper Otherb Table 2.2 % and 33. and in four of the eight countries female attempters were more likely to be single than married. armed force.5 % males.3 % females) and in Tallinn (13. retired. (Table 3).6 % females). Other includes sick leave/disabled. a combination of methods. Campinas and Tallinn were the only sites where the median age of females was higher than for males (Table 1). Divorce was common among suicide attempters in Campinas (17. ‘hanging ’. etc. The other common employment categories were ‘unemployed ’. far exceeding the other methods of ‘ cutting ’. F. in Colombo and Chennai it was the most commonly used method in men (43. women were more frequently married than men (Table 2).8 % respectively) . Main method of the suicide attempt according to ICD-10 codes Self-poisoning – which accounted for 69–98 % of all cases – was the predominant method of suicide attempts seen in the emergency departments at all sites. female attempters were more likely to be married than male attempters (Table 2). In Yuncheng pesticide ingestion was the most frequently reported method among both men (61. female. Socio-demographic characteristics of suicide attempters seen at emergency-care hospitals in SUPRE-MISS sites (% rounded) M. Male .5%) and women (71. Except for Durban and Karaj the majority of subjects were employed full-time or part-time at the time of admission to the emergency-care departments. 22.6 % and 23. temporary work.6 %) . b (n=155) 68 19 13 (n=152) 3 38 51 7 1 (n=142) 40 29 18 1 8 years (Campinas and Yuncheng) and from 23 (Karaj) to 33 years (Yuncheng) among males. a Separated/divorced or widowed.e.8 % respectively) and the second most commonly used method in women (19.

Male . . but no danger to life. b Other. ‘ Medical attention/surgery required. all firearms . Male . Campinas Chennai Colombo Durban Hanoi Karaj Tallinn Yuncheng Main method of attempted suicide according to ICD-10 codes in SUPRE-MISS sites (% rounded) M F M F M F M F M F M F M F M F (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) 0 39 2 0 18 13 72 2 18 9 12 0 1 6 6 6 1 1 1 3 2 4 6 2 7 5 79 6 4 33 0 34 21 97 3 0 40 0 24 17 98 1 0 8 1 43 17 91 2 2 16 0 20 19 93 1 1 9 0 2 17 86 5 4 17 0 3 16 96 2 2 2 0 16 16 89 7 2 2 0 5 5 98 2 0 11 1 3 16 91 1 6 13 1 2 21 96 0 2 3 2 1 4 69 7 20 2 1 0 3 88 5 6 2 58 8 12 8 11 10 6 4 10 51 47 50 59 2 1 5 14 27 48 54 52 75 9 13 11 22 0 31 0 0 62 5 97 3 0 0 0 21 3 0 72 2 98 3 0 0 Self-poisoning Non-opioid analgesics and antipyretics Anti-epileptic and sedative-hypnotic drugs Other medicaments Alcohol Pesticides Othera All Poisonings Hanging and suffocation Cutting with sharp or blunt object Otherb M. not elsewhere classified . jumping or lying before a moving object . Chennai M F M F M F Colombo Durban Consequences of the attempted suicide and care in the SUPRE-MISS sites (% rounded) Hanoi M F M Karaj F M Tallinn F Yuncheng M F Campinas F M Suicide attempts in developing countries’ emergency care Physical consequences None Mixa Yesb 28 35 37 (n=43) 9 79 5 7 0 25 75 0 34 66 16 47 37 20 52 28 20 77 4 (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) 18 76 6 6 65 30 8 81 11 11 74 15 12 77 11 3 53 44 3 59 37 0 33 67 0 20 80 18 30 53 Referral (n=28) None 7 General health care 68 Psychiatric care 21 Private 4 (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) 98 98 62 67 12 12 74 82 48 47 16 28 97 99 0 0 9 7 2 4 7 5 40 42 28 20 0 0 2 2 30 26 86 84 19 13 6 5 55 50 3 1 0 0 0 0 1 1 0 0 6 6 1 2 0 0 1471 73 b M. other drugs acting on the autonomic nervous system . ‘Medical attention/surgery required. smoke. including : narcotics and psychodysleptics. other and unspecified chemicals and noxious substances. including drowning . female. female. Table 4. a Self-poisoning other. F. organic solvents and halogenated hydrocarbons and their vapours . a Mix. unspecified means. other gases and vapours . other specified means . jumping from a high place . fire.Table 3. F. steam and hot objects . had/has danger to life ’.

3% for women). medications or other poisons accounted for 69–98 % of all suicide attempts identified in the emergencycare units of the eight sites included in the study. it is the first data on attempted suicides ever collected or published both in national and international periodicals.5 % for females).6 which is similar to that reported in the WHO/EURO multicentre study [1 : 0. Despite careful preparations.3 (Schmidtke et al. 1996 .8%) and in Chennai (97. both sexes).1 to 1 : 2. particularly in China. Practically no referral to any professional service was made in Yuncheng for both men (97. 2003 . 1993 . 2004)]. This sample of attempted suicides identified in emergency rooms of hospitals in eight developing countries is. with the exception of Campinas (23. 1996 .6% of the males and 65. in some sites a few subjects managed to slip through. Consequences of the attempted suicide and care 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 (80. Eddleston. a high proportion of the subjects in this study were married at the time of their attempt. self-poisoning is the most common method of suicide attempt. most subjects required a combination of medical attention or surgery.1472 A. Eddleston & Phillips.2 % of the females and 66.9 % of the females) and Campinas (52. 2004). 98. i. In the remaining sites. 2002 . For several of the participating countries. and Sri Lanka.1 %.9% for women) and Tallinn (34 % for men). transfer to a psychiatric institution ranged from 0% to 34 % . 2005). India.e. which reflects the non-existence of eligible referral services in these locations.6% of the males). Chennai (74. In some sites the number was not known (although believed to be very small). Schmidtke et al. Refusals were strongest in Colombo (up to 38.4–85. suggesting that marriage is not a strong protective factor for suicide attempt in developing countries (WHO. 2000. like those identified in developed countries (Diekstra. 2002 b). in most of the sites it was very low (between 0 % and 8 % of the cases). 2002 . 1996. primarily composed of young adults. The situation in virtually all participating emergency settings is such that suicide attempts are not recorded on a routine basis. In Hanoi. and the ingestion of pesticides. In four of the eight sites less than one-third of subjects received any type of referral for follow-up evaluation or care (Table 4). Phillips & Li. With regards to the type of care. Similar to other countries. resulting in a lack of data to estimate rates of suicide attempts. 74 . Colombo and Karaj the amount of non-referral was equally dominant among both men and women (46. A separate question regarding the acceptance of an offer of professional care. pesticides are a more common method of self-poisoning in developing countries. the patients were mainly sent to a psychiatric out-patient clinic (50.9–79. In Durban and Tallinn. Fleischmann et al.5–81. Gunnell & Eddleston. DISCUSSION This is the first study to provide detailed information on cases of suicide attempts from a wide range of developing countries.6% for men.4%) and women (98. Unlike reports from developed countries (Lohr ¨ & Schmidtke.7 % of the males). Nevertheless. Latha et al. These findings strongly support earlier reports on the role of pesticide poisoning in attempted and completed suicide in developing countries (Latha et al. both sexes).7 to 1 : 2. which was not linked to the referral. 2004). they would accept to go to the consultation offered. In Campinas referral was primarily made to a general health-care or primary health-care centre (67. An effort was made to collect for the first time this basic intake information from all suicide attempters in the emergency-care settings. in other sites at least sex and age of those not completing the intake were known (allowing a comparison of those who did and did not participate in the intake).7%. Phillips et al. was answered positively by the majority of subjects.7%). Thanh et al. The male : female gender ratio in the eight countries ranged from 1 : 1. but there was no danger to life (Table 4). and in a third group of sites all subjects were part of the intake. Future thorough analyses specifically addressing sample issues will provide a sense of how representative the reported cases are.

D. 100–108. Iran. & Schmidtke. M. Bille-Brahe. D. X. The magnitude and causes of the problems vary across the countries included in this study. (2004). Hawton. availability. Recommended care for young people (15–19 years) after suicide attempts in certain European countries. Karaj : Iran National Research Center for Medical Sciences. A. QJM Monthly Journal of the Association of Physicians 93. Patterns and problems of deliberate selfpoisoning in the developing world. I. largely due to cultural and socio-economic factors. including the analysis of regulations. W. SalanderRenberg. Michel.. (2003). Schmidtke. Kerkhof. Platt. W.. Eddleston. In Preventive Strategies on Suicide (ed. Gulbinat.) 371. the current situation leaves plenty of room for improvement of the health services. U. G.. with local emphasis on the most used substance. where both first authors are employed. therefore. Latha. & Phillips. A. A. Kerkhof. & Querejeta. Sweden [within the collaboration between the Swedish National and Stockholm County Council’s Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) at the Institute for Psychosocial Medicine (IPM) and the Department of Public Health Sciences at the Karolinska Institute and Hanoi Medical University]. failing to collect essential information or to provide follow-up referrals.. Our study has highlighted several of the difficulties that need to be overcome to rectify this problem : incomplete or inaccurate registration of persons seen in emergency departments . K. This results in a situation where the care is limited to somatic symptoms only. (2000). where it is relevant. access. 2003). WHO Regional Office for Europe: Copenhagen. R. J. Roberts et al. A. Estonia . International Journal of Epidemiology 32. Accurate. S. The epidemiology of suicide and parasuicide. however.g. In Facts and Figures : WHO/EURO (ed. & Eddleston. R. Another important finding was the relative lack of professional services for referral of suicide attempters... T. This result calls for immediate action on this issue. administrative and attitudinal changes. the emergency departments of hospitals in both developed and less-developed countries are not currently able to collect this information. R. M. Bhat. (1995).. 1995. Sweden. Hanoi : Swedish International Cooperation Development Agency (SIDA). European Child and Adolescent Psychiatry 9. A. Jiang. Wasserman.. Tallinn : Estonian Health Insurance Fund. K. a continuing tragedy in developing countries. Suicide attempters in a general hospital unit in India : their socio-demographic 75 . W. 2001) and (in some cases) legal sanctions.. DECLARATION OF INTEREST None. De Leo). psychiatric assessment and referral were not delivered in a systematic way or as part of a routine which is in agreement with a study from Europe regarding young suicide attempters ´ (Hulten et al. An example of a suicide prevention program in a developing country. standardized information on the rates and characteristics of medically treated suicide attempts is essential to the development and evaluation of preventive services. Stockholm. Eddleston. 715–731. M. 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 (Wasserman. M. European Parasuicide Study Interview Schedule (EPSIS). Suicide by intentional ingestion of pesticides . World Health Organization.. Kienhorst and D. Even in those places where psychological or psychiatric services were available. (1996). 2000).Suicide attempts in developing countries’ emergency care 1473 It has been shown repeatedly that restricting the access to and the availability of the prevailing method can be effective in reducing the frequency of suicide attempts (Bowles.. pp. S. 9–20. R. F. M. Rectifying these problems will require substantial legal. Self poisoning with pesticides. U. Bjerke. e. U. W.. British Medical Journal 328. and packaging of these substances. pesticides in these Asian countries. & D’Souza. F. Acta Psychiatrica Scandinavica (Suppl. distribution. In these places. Diekstra. 42–44. the Swedish National and Stockholm County Council’s Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) at the Institute for Psychosocial Medicine (IPM) and the Department of Public Health Sciences at the Karolinska Institute. Tehran.. Stockholm. 902–909. Bernasco. (1993). S. (1999). ´ Hulten. Bille-Brahe. ACKNOWLEDGEMENTS The study was funded by the Department of Mental Health and Substance Abuse. Bille-Brahe). clinicians not recording routinely suicide attempts as such and. P. 173–206. (2000). I. Brill : Leiden. and for prompt intervention after the intoxication. Diekstra. Gunnell. REFERENCES Bowles. Tallinn. E. K. Some field research sites obtained additional funding from the following agencies. or (in some cases) because they wish to avoid legal proceedings.

& Li.. C. U. (1992).1474 A. D. Attempted suicide in Hanoi. & Zhou. Crepet. J. Haring. Y.. A. ¨ 76 . H. M. S. B. K. (2004). Roberts. A.. D. M. R. Van. De Leo. World Report on Violence and Health. Rosling. Influence of pesticide regulation on acute poisoning deaths in Sri Lanka. U. Sheriff. L. Michel. U. I. T. H. Acta Psychiatrica Scandinavica 85... Buckley. World Health Organization: Geneva.. J. & Wasserman. Suicide rates in China. Schmidtke. Parasuicide in Europe : the WHO/EURO multicentre study on parasuicide. Lancet 360.. B. and clinical profile – emphasis on cross-cultural aspects. C. Schmidtke). Karunarathna... Querejeta. Bille-Brahe. Thanh. (2005). (2002). D.. WHO (2002 a). Guidelines for the Formulation and Implementation of National Strategies. Dunitz : London. M. 26–30. United Nations: New York. United Nations Department for Policy Coordination and Sustainable Development (1996). Schmidtke. G. Fricke. Michel. D. Phillips. K. A. M... G. U. Lonnqvist. Schmidtke. T.. Bjerke. Ji. P. & Schmidtke. Social Psychiatry and Psychiatric Epidemiology 40. D. Bjerke. K. 64–71... Kerkhof. Zhang.. P. P. Querejeta.. Acta Psychiatrica Scandinavica 94. 835–840. World Health Organization: Geneva. Platt. (eds).. Lancet 359. X.. World Health Organization: Geneva. S. Risk factors for suicide in China : a national case-control psychological autopsy study. 1–10.. Attempted suicide in Europe: rates.. H. I. ¨ Phillips. D. Salander-Renberg. (1996).. Wasserman. T... (2004). Kerkhof and A. Pommereau. De Leo. M. Philipe. D... (2002). Wang.. Suicide : An Unnecessary Death. N. & Kerkhof. Hogrefe & Huber: Gottingen. Introduction and preliminary analysis for 1989. Results of the WHO/EURO Multicentre Study on Parasuicide. Bille-Brahe. E. (2003). 327–338.. Acta Psychiatrica Scandinavica 93. Kerkhof. The World Health Report 2003: Shaping the Future. 1728–1736. I... Lonnqvist. A.. J. A. G. T. Temesvary. Wasserman. Jiang. D. 1995–99. Temesvary.. & Sampaio-Faria. (2001).. Bulletin of the World Health Organization 81. WHO (2003). M. Wasserman. N. X. ¨ Lohr. Crepet... Minh. 97–104. Weinacker. Hawton. Salander-Renberg.. I. Pommereau... A. D. G. Fleischmann et al. C.. Manuweera. J.. Haring. A... Bille-Brahe. In Suicidal Behaviour : Theories and Research Findings (ed. Yang.. A. Vietnam. H. trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Hogrefe & Huber : Gottingen. Bille-Brahe. T. De Leo. B.. G. Marital relations of suicide attempters. X. Suicidal behaviour in Europe : Results from the WHO/ EURO Multicentre Study on Suicidal Behaviour. R. T. Prevention of Suicide. R. & Eddleston.. A. E. X. & Sampaio-Faria. D. Philippe.. A. WHO (2002 b). Multisite Intervention Study on Suicidal Behaviours SUPRE-MISS : Protocol of SUPRE-MISS. De Leo. A.

II .

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

Suicidal intent.62:431�435.sisask@neti. Analysis by gender and age groups revealed also significant correlations with two exceptions only: correlation between suicidal intent and hopelessness did not reach the significant level in males and in older adults (40�). Estonia.Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt ¨ ˜ MERIKE SISASK. DANUTA WASSERMAN Sisask M. Oslo. Beck Hopelessness Scale for hopelessness. Suicidal intent correlated the most strongly with well-being. Subjective psychological well-being ˜ ¨ (WHO-5) in assessment of the severity of suicide attempt. E-mail: merike. A comparable scale. Accepted 5 December 2007. Kolves K. Wasserman D. S uicide risk assessment is an important issue and at the same time a complicated task.05). Taylor & Francis As) 79 . depression and hopelessness. The Beck Depression Inventory (BDI) (7) is a selfreported inventory currently widely used both in clinical practice and research for identifying symptoms of depression and measuring its severity. Aspects of suicide risk like suicidal intent. Well-being. depression. The WHO-5 well-being scale. An objective way to measure the severity of suicide attempt is to use different psychometric scales. essentially a modification of Beck Suicide Intent Scale. The data on suicide attempters (n �469) was obtained in Estonia (Tallinn) by the WHO Suicide Prevention*Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) methodology. ’ Depression. Oie 39. 2). All psychometric scales correlated well with each other (PB0.ee. An objective way to measure the severity of suicide attempt is to use different psychometric scales. Empirically defined affective and cognitive experiences of suicidal persons are depression and hopelessness. Hopelessness. is the Pierce Suicidal Intent Scale (PSIS) (4). WHO-5 for well-being). Different psychometric scales were used to measure suicidal intent (Pierce Suicidal Intent Scale) and emotional status (Beck Depression Inventory for depression. but it is even more strongly correlated with lack of positive thoughts about the future (9).1080/08039480801959273 # 2008 Informa UK Ltd. Nord J Psychiatry 2008. 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 suicide attempters measured by depression. KAIRI KOLVES. can be used in settings without psychological/psychiatric expertise in preliminary suicide risk assessment. The Beck DOI: 10. 2) to test the applicability of well-being measured by the World Health Organisation well-being index (WHO-5) in suicide risk assessment. ˜ Merike Sisask. There are indicators that 60�70% of patients with acute depression experience suicidal ideas and 10�15% of depressive patients commit suicide (5). ISSN 0803-9488. hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure (1). hopelessness and well-being scales in different gender and age groups. One of the most well-known scales for assessment of the severity of suicidal intent is the Beck Suicide Intent Scale (3). which is a short and emotionally positively loaded instrument measuring protective factors. Aspects of suicide risk like suicidal intent. AIRI VARNIK. (Informa Healthcare. KENN KONSTABEL. Konstabel K. Tallinn 11615. Depression is a psychiatric diagnosis most strongly linked with suicide (6). 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. Varnik A. depression. Suicidal intent scales are developed to measure the severity and intensity of suicidal thoughts and plans (1. Low level of well-being associated with high level of suicidal intent. Estonian-Swedish Mental Health and Suicidology Institute. Severity of suicide attempt. Both scales are in general not used as clinical suicide risk assessment scales but rather as scales in research studies to classify suicide attempters. hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure.

with the possible total score varying from 0 to 25 NORD J PSYCHIATRY×VOL 62×NO 6 ×2008 2) Material and Methods Data collection In 2000. The need to assess the utility of the WHO-5 in the context of detecting suicidal ideation has been pointed out (26). the total score has a theoretical range from 0 to 20 (Cronbach’s alpha �0.6914. 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 suicide attempters measured by depression. The response rate was 53% and the main reasons for exclusion were suicide attempters’ refusal and leaving the hospital before interview was conducted. Description of subjects The research subjects were 469 suicide attempters. x �18.M SISASK ET AL. n�178. s�11. a revised version of the original Pierce Suicidal Intent Scale (PSIS) was used (4. n �440. 28. x�9.3%) males and 308 (65. n �157.222). 28). ‘‘I have felt calm and relaxed’’.1 years*for males 31. The mean age (9standard deviation. ‘‘I have felt active and vigorous’’. the study was conducted by the Estonian� Swedish Mental Health and Suicidology Institute (ERSI). in the current research a higher score refers to more severe hopelessness. The WHO-5 has been found to be a sensitive and easily used instrument for depression screening in the primary care (19�22). ‘‘My daily life has been filled with things that interest me’’) were assessed on a 6-score scale (from never to always). n �134. younger adults (25�39 years.35. although it reflects also aspects other than just the absence of depressive symptoms (23�25). Higher score refers to more severe depressive status.77. Hopelessness is highly associated with depression and suicidal behaviour (11�14) and it has been considered a key variable linking depression to suicidal behaviour (15.7%) females. x�8.54). The occurrence of depression was assessed by the means of 21-item Beck Depression Inventory (BDI) (7). To be in line with other scales opposite to the original scale. Scales For defining the severity of suicide attempt.8 years and for females 33.24. All suicide attempters identified between December 2001 and January 2004 by medical staff in the emergency-care settings of the Northern Estonian Regional Hospital 432 80 .2. developed by Bech in the 1990s to measure the subjective level of people’s wellbeing (18). 33. A one-item modification of this multiple-item scale has been also proved to measure hopelessness in an adequate way (10). The interviewed suicide attempters were representative by gender and age for all suicide attempters seen at the emergency care department during the study period. Hopelessness Scale (BHS) (8) is one of the most frequently used self-reported questionnaires in research of hopelessness and predicting suicide.42). Negative attitude towards the future was assessed on the Beck Hopelessness Scale (BHS) (8) and on its oneitem modification. were invited to participate in the study.35).91. the Aish & Wasserman scale (10). The Aish & Wasserman scale consists of one statement (‘‘My future seems dark to me’’). There is rather little research available to the best of our knowledge about the role of well-being in understanding suicidal behaviour. The methodology of SUPRE-MISS was elaborated by a WHO expert group and adapted to local conditions (27. s�4. s) of suicide attempters was 32.5911. ‘‘I have felt fresh and rested’’. The WHO well-being index (WHO-5) is a relatively new instrument.2915. The scale consisted of 12 questions and possible total score ranged from 0 to 24 (Cronbach’s alpha �0.0%). The suicide attempters were divided in analysis into the following age groups: youth (15�24 years. The possible range of score was 0 to 63 (Cronbach’s alpha �0. Assessment of well-being was performed using the WHO well-being index (WHO-5) (18). The original scale consists of 20 statements to be rated dichotomously (true vs. P�0. The study was conducted in five continents. SUPRE-MISS (Suicide Prevention*Multisite Intervention Study on Suicidal Behaviours). Higher score refers to more severe suicide attempt. In Estonia. Those who agreed filled in a consent form and a structured in-depth interview was conducted as soon as their medical condition had stabilised. To test the applicability of well-being measured by WHO-5 in suicide risk assessment. n�448.90. Five statements presented (‘‘I have felt cheerful and in good spirits’’. with the main objective of reducing the mortality and morbidity associated with suicidal behaviour.6%).5%) and older adults (40 and older. s �5. the World Health Organization (WHO) launched the worldwide intervention study on suicidal behaviour. The Tallinn Medical Research Ethics Committee gave approval for the study in Estonia. one of the participating centres was Estonia (Tallinn). The difference in mean age between males and females was statistically non-significant (t��1. hopelessness and well-being scales in different gender and age groups. 38. n�469. false). An ecological study has confirmed the inverse association of suicide rate with life satisfaction and happiness as indicators of population well-being (17).1 years.93. The interviewers were clinically experienced specialists (psychiatrists and psychologists). 28). 161 (34. 16).

05.959 12. Well-being measured by WHO well-being index (WHO-5) turned out to be an important issue.11 9.68 10.78) (96.001 B0. Beck Hopelessness Scale (oneitem ‘‘My future seems dark to me’’).01 17.001 (Cronbach’s alpha �0. The reliability of scales was assessed using the internal consistency coefficient* Cronbach’s alpha.22) (911.36) (911. The correlations between different scales are presented in Table 2.01 9. BDI. In assessment of correlations between the scales.402 0.36 7.51) (90. s�5.49 (94. along with already well-known characteristics and risk factors of suicide attempt like depression and hopelessness.59).48) 5. Suicidal intent was negatively correlated with wellbeing.348 0.40 (94. WHO-5. Well-being was correlated negatively with impaired emotional status as assessed by all other scales*the lower well-being the higher score of depression and hopelessness.939 0.50) 8.63 (94.73) (95.78 11.68) (95.35 0. Correlation was the strongest with depression. 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). The differences of mean scores were calculated using a t-test for genders and analysis of variance (ANOVA) for age groups. the hopelessness scale can be shortened without losing important information (10. Age group 40�(9s) Results The mean scores of different scales did not differ by gender. PSIS. 15�24 (9s) P-value t-test Females (9s) Gender Discussion As expected.49) 8. Correlations between different scales were also on a significant level in analysis by gender and age groups.54 (94.21 20. BHS/multi.485 12.35) (95.14) (95. n�466. Beck Depression Inventory.85 0.188 9.37 19.63) (95. Multiple-item and one-item hopelessness scales had similar results. by gender and age groups).50) 8.50) 9.001 B0.50) �0.675 1.90 10.73 8.63 10.838 �1. and positively with depression and hopelessness.61) (90.52 15.78) (95.79 9. NORD J PSYCHIATRY ×VOL 62×NO 6×2008 Males (9s) Total (s) PSIS BDI WHO-5 BHS/multi BHS/one 8.46) (90.001 B0.27) (90.75) (911. Higher score refers to better well-being.36) (95. a Spearman correlation coefficient was used.71 9. 25�39 (9s) Table 1. 29).20) (910.WELL-BEING AND SEVERITY OF SUICIDE ATTEMPT The statistical analysis was performed with the SPSS (version 14.24 18.41) (94.854 8. Multiple-item and one-item hopelessness scales had similar correlations with other scales with only minor variations in magnitude of the correlation coefficient.71 0. BHS/one.699 0.01) (95. P-value 433 81 . Lower well-being and higher depression or hopelessness referred to more severe suicidal intent.93. Beck Hopelessness Scale (multiple-item).59) (95.41) (90.54) (90. Mean scores of different scales filled in after suicide attempt (total.18 0.992 Statistical analysis F 0. which confirms the previous suggestions that in order to be less stressful for interviewees to answer.51 (94.11.003 B0.220 0.93 9.090 0.42) (911.285 7.53 (94. The level of statistical significance was set at a �0. WHO well-being index.53 9. but increased (in the case of well-being* decreased) statistically significantly with age (Table 1).25 21. Correlations between WHO-5 and other scales were all at a significant level. Suicidal intent correlated the most strongly with well-being.0) program. the severity of the suicide attempt correlated with the level of depression and hopelessness.68) (95.095 0.54) (910. Pierce Suicidal Intent Scale. �10.69 0.97 0.

415* 0.333* 0. �0.285* 0. the Swedish National and Stockholm County Council’s Centre for Suicide Research and Prevention of Mental IllHealth (NASP).307* �0.418* �0. M.502* 0.151 BDI WHO-5 BHS/multi �0. which could be hidden by patients because of shame and stigma associated with psychic disorders (35).578* �0. Herman I. a project funded by the World Health Organisation and the participating field research centres. editor. �0.013 0. NORD J PSYCHIATRY×VOL 62×NO 6 ×2008 434 82 . London: Martin Dunitz.412* �0. shifted towards measuring cheerfulness and the level of energy. Chennai.664* 0. Campinas. social. Watson D.531* 0. What is remarkable is that both multiple-item and one-item hopelessness scales demonstrated similar results.785* *Significant at the 0. and Professor D.538* 0. physical and psychological (30�32).209* 0. especially in settings without psychological/psychiatric expertise. Crisis 2001. Varnik.341* �0. Professor L. Suicide: An unnecessary death. MD: Charles Press.156 0. 147�57. Geneva. Colombo. The concept of well-being has a complex multidisciplinary nature comprising different dimensions on both an individual and societal level*economic. the WHO-5 is a screening instrument to select vulnerable subjects and further specific suicide risk assessment is mandatory. The Tallinn centre obtained additional funding for data collection and analysis from the following agencies: the Estonian Health Insurance Fund. The Collaborating Investigators in this study have been (in alphabetical order): Dr J. Development of Suicidal Intent Scales.328* �0.339* 0.608* 0. Beck Depression Inventory. Dr M.801* Conclusions The current study demonstrated that in understanding the severity of the suicide attempt studied. groups and nations to thrive and flourish’’ (33). Bech P.562* �0. A list of other staff contributing to the project can be obtained from WHO.475* 0. 1974. depression and hopelessness in suicide attempters. It is References 1.254* 0. Short and positively loaded scales like the WHO-5 measuring protective factors should be preferred for preliminary suicide risk assessment.408* 0. 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 hopelessness.377* 0.231* 0.784* �0. Bowie. Psychometric scales in suicide risk assessment. Dr L. Schuyler D. In: Beck AT.535* �0. Raabaek Olsen L. The strong side of the WHO-5 is its shortness and positive questions.292* �0. Beck Hopelessness Scale (multiple-item). Tran Thi Thanh. Beijing.22:12�4.343* 0.598* 0. correlating well with each other. Merritt M. 36). The prediction of suicide. ¨ Dr J. Lettieri DJ. 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). Geneva. Table 2. Professor D. PSIS Total BDI WHO-5 BHS/multi BHS/one Males BDI WHO-5 BHS/multi BHS/one Females BDI WHO-5 BHS/multi BHS/one Age group 15�24 BDI WHO-5 BHS/multi BHS/one Age group 25�39 BDI WHO-5 BHS/multi BHS/one Age group 40� BDI WHO-5 BHS/multi BHS/one 0.291* 0. p. Tehran.133 0. De Leo. Bertolote and Dr A. However. 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). Correlations between different scales filled in after suicide attempt (total. Beck AT. BHS/ multi. Bolhari. Fleischmann have coordinated the project at WHO Headquarters. editors.365* �0. the Karolinska Institute and the Estonian Scientific Foundation (Project No 7132). The measurement of suicidal ideation. A low level of subjective psychological wellbeing is associated with high level of suicidal intent. scales measuring emotional status could be served as useful instruments. Pierce Suicidal Intent Scale. Beck Hopelessness Scale (one-item ‘‘My future seems dark to me’’). Nimeus A. Vijayakumar. 3. 2. which are not too difficult to answer (34). Therefore. Hanoi. Goldney R.543* 0.519* �0. Stockholm. WHO-5. Phillips. PSIS. Acknowledgements*This paper is based on the data and experience obtained during the participation of the authors in the WHO Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS). 45�56. One possible way to define well-being is: ‘‘a positive and sustainable state that allows individuals. Professor A.332* 0. Dr D.244* 0. the WHO Lead Collaborating Centre at the Department of Public Health Sciences. BHS/one. Botega.05 level. WHO Well-Being Index. p.M SISASK ET AL. Dr H.273* �0. Fisher L. Tallinn.214* 0.586* �0.448* �0. De Silva.524* �0. Brisbane.181* 0. 2001. The positive questions of the WHO-5.234* 0. have acted as scientific advisors for the WHO SUPRE-MISS study.364* �0.694* 0.366* �0. It has been argued that psychometric scales to be used in a daily clinical setting should be simple and brief (1). Schlebusch.795* 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 (19. which are associated with suicidal behaviours. Durban.790* �0.764* �0.320* 0. Wasserman.295* 0. BDI.407* �0. Professor N. In: Wasserman D.507* 0.641* 0. by gender and age groups).359* 0.282* 0.694* 0. Resnick HLP. work in the screening of depression as successfully as the questions narrowly oriented on depressive symptoms.

Mergl R. Phil Trans R Soc Lond. 2003. Steer RA. 28. Nimeus A. Maier W. p. 11. 39�47. Nord J Psychiatry 2006. Practical guideline for dealing with depression]. Lucas RE. University of Tartu. University of Tartu. Haviland-Jones JM.326:200�1. In: Wasserman D. Tallinn University.99:171�8. Weissman A. MacLeod AK.359: 1331�2. Huppert FA. Weissman A.23:139�45. Heun R. Gen Hosp Psychiatry 2004. suicidality and suicide prevention in affective ¨ disorders. Estonia. Bech P. Hopelessness. Tallinn. 2002. 16. et al. The social context of well-being. Kuriyama S. 34.and middle-income countries. De Leo D. J Affect Disord 2004. Beck AT. 27. Henkel V. Estonian-Swedish Mental Health and Suicidology ˜ Institute. 7.11:22�30. ¨ Screening for depression in primary care: Will one or two items suffice? Eur Arch Psychiatry Clin Neurosci 2004. Jessen F. Paris J. suicidal ideation. Br J Clin Psychol 2005. Regional Office for Europe. Suicide Life Threat Behav 1993. Mock J. Diener E. J Consult Clin Psychol 1974. 31. 9. Allgaier AK. p. Kenn Konstabel. depression and suicidal intent in parasuicide. 325�37. Gunnell D. Suicidal intent in self-injury. Sisask M. Fleischmann A. Kjoller M. depression. Henkel V. Estonia. Handbook of emotions.12:85�91. Acta Psychiatr Scand 1999. [From patient screening to management list in suicide risk.39:497�501. An inventory for measuring depression. Huppert FA. Bech P.4:13. Helliwell JF. Soc Psychiatry Psychiatr Epidemiol 2006.(418):73�80. 18. Estonia. Bray I. suicide attempts. Crisis 1990. 22. Keverne B. Lo B. Hegerl U. Estonia. Psychol Med 2005. Biol Sci 2004. Beck AT. Moller HJ. Tallinn. Tallinn University. Bertolote JM.130: 377�85. and suicidality*A 13-year community-based study. Well-being: Towards an integration of psychology.31:367�72. Merike Sisask. B. Aish AM. Kreitman N. Suitsid* ¨ naprasnaja smert. Quenter A. Primack BA. Cheung YB. Putnam RD. Althaus D. Newman CF. Brezo J. Tallinn. Botega N. Tartu: Tartu Ulikooli Kirjastus. Baylis N. MMW Fortschr Med 2003. National Prevention of Suicide and Mental Ill-Health (NASP) at Karolinska Institute and Stockholm Country Council’s Centre for Suicide Research and Prevention. Burkart M. 25. B. editor. Coyne JC. Davidson K. BMJ 2003. Wasserman D. Fredriksborg: World Health Organisation. Estonian-Swedish Mental Health and Suicidology ¨ Institute. Quick assessment of hopelessness: A crosssectional study. Kuo WH. Hopelessness. Erbaugh J. Validity and utility of the Japanese version of the WHO-Five WellBeing Index in the context of detecting suicidal ideation in elderly community residents. Phillips M. et ¨we ¨ al. 21. 12. Info Package: Mastering depression in primary care. Eaton WW. Validity of the fiveitem WHO Well-Being Index (WHO-5) in an elderly population.42: 861�5. 35. Hopelessness. Affective disorders and suicide. Int Psychogeriatr 2006:1�12. Tata P. Olsen LR. Beck AT. 157�63. depression. WHO Lead Collaborating Centre of Mental Health Problems and Suicide Across Europe. Personality traits as correlates of suicidal ideation.44(Pt 4):495�504. Subjective emotional well-being. Zipfel S. Psihometritsheskije shkalo ˜ otsenki suicidalnogo riska. Ward CH. Bech P. editors.251 Suppl 2:II27�31. Rasmussen NK. Biol Sci 2004. 32. Wasserman D. 10. Measuring well-being rather than the absence of distress symptoms: A AND SEVERITY OF SUICIDE ATTEMPT comparison of the SF-36 Mental Health subscale and the WHOFive Well-Being Scale. Seki T. Barkow K. 37. Tallinn. JAMA 1975.254:215�23. 2001. 6. Sweden. 33.145:24�7. Grafe K. Weishaar ME. Hegerl U. Beck JS. 20. editor. Spitzer RL. 36. et al. London: Martin Dunitz. Kohnen R. Kohnen R.139:48. Awata S.144:127�33. Does Beck’s Hopelessness Scale really measure several components? Psychol Med 2001.4: 561�71. General health and well-being in outpatients with depressive and bipolar disorders. Mergl R. 23. Mendelson M. Koizumi Y. Phil Trans R Soc Lond. Estonia. WHO. 15. Kovacs M. Moller HJ. ACP J Club 2003. Soc Psychiatry Psychiatr Epidemiol 2004. An overview. Arch Gen Psychiatry 1961. 2nd edition.359:1447�51. Schmidt U. Henkel V. Hopelessness and positive and negative future thinking in parasuicide. 1998. Raabaek Olsen L. Pierce DW. Kohnen R.234:1146�9. Introduction: Why do we need a science of well-being? Phil Trans R Soc Lond. Biol Sci 2004.78:131�40. 5. Hansen HV. NORD J PSYCHIATRY ×VOL 62×NO 6×2008 435 83 .359:1435�46.41:333�7. and suicide completions: A systematic review. Lester D. ¨ Use of brief depression screening tools in primary care: Consideration of heterogeneity in performance in different patient groups. Tyrer P. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. life satisfaction and happiness as markers for population mental health. Bech P. In: Wasserman D. Hozawa A.WELL-BEING 4. 8. Gallo JJ. 13. In: Lewis M. Estonia. 29. The WHO-5 Wellbeing Index performed the best in screening for depression in primary care. Dyer JA. National Institute for Health Development. Suicide risk assessment and prediction. Mergl R. Beck AT.26:190�8. p. B. Int J Methods Psychiatr Res 2003. 14. Kairi Kolves. The measurement of pessimism: The hopelessness scale. Moller HJ. Estonia. Eur Arch Psychiatry Clin Neurosci 2001. Estonia. Baylis N. Trexler L. Maier W. 30. Hopelessness and suicidal behavior. Bonsignore M. Multisite Intervention Study on Suicidal Behaviours SUPRE-MISS: Protocol of SUPRE-MISS. Suicide rates. Br J Psychiatry 1977. Stockholm. Yip PS. Hegerl U. Airi Varnik. Suicide: An unnecessary death. Danuta Wasserman. Bech P.60:150�6. Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low. Hegerl U. Acta Psychiatr Scand Suppl 2003. ¨ Identifying depression in primary care: A comparison of different methods in a prospective cohort study. WHO. 2000. New York: Guilford Press. 17.35:1467�74. Br J Psychiatry 1984. Turecki G. Psychiatric Research Unit. neurobiology and social science. Thompson S. Estonian-Swedish Mental Health and Suicidology Institute. Moller HJ. Suicide.113:180�206. Acta Psychiatr Scand 2006. Kroenke K. 19. Beck AT. Geneva: WHO. Health Qual Life Outcomes 2006. Heun R. substance disorder. Internal and external validity of the WHO Well-Being Scale in the elderly general population. 24. 26. and clinical diagnosis of depression. Kessing LV.

.

III .

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

1995. Psychometric scales are available to measure levels and various aspects of suicidal intent. The term level of suicidal intent is used to describe the intensity of a death wish (Hjelmeland & Hawton. 1979. but equivocal communication (components termed “arrangements” and “circumstances”) increased with age. Beck et al. 2Tallinn University. 2001). Classified in age groups. 2000.4. & Nimeus. and suicidality has been described as a continuum from the lowest (weariness of life. but nonverbal suicidal communication also expresses suicidal intent.2. Background: Suicidal intent is an essential feature of suicidal behavior. but there are also nonsuicidal conscious or unconscious purposes. 30(3):136–143 © 2009 Hogrefe Publishing Research Trends Severity of Attempted Suicide as Measured by the Pierce Suicidal Intent Scale Merike Sisask1. such as trying to manipulate others or escape from an intolerable situation (Andriessen. and duration of hospitalization were linked to suicidal intent. Suicidal intent evolves during the suicidal process and levels of suicidal intent at different stages of the suicidal proCrisis 2009. Tallinn. The development of suicidal behavior has been characterized by the model of suicidal process. 1994).2. Australia. but rather a scale designed for use in research studies to classify suicide attempters (Bech. Vol. Berman. & Waeber. and Airi Värnik1. Michel. Tartu. Psychiatric diagnosis. Stockholm. Estonia. & Weissman. components of suicidal intent. Estonia. Results: The level of suicidal intent was not gender-dependent. 2004). Tallinn. One of the best-known scales. & Herman. Kovacs. Wasserman. especially in the presence of others (Lester. 30(3):136–143 DOI 10. and variables indicating the severity of attempted suicide. Males and females were also similar in terms of discrete components. Pierce Suicidal Intent Scale.1027/0227-5910. Estonian Centre of Behavioral and Health Sciences. but rose with age. one example being the particular way in which a suicidal act is carried out. This is primarily because it permits a distinction to be drawn between accidental and suicidal behavior (Andriessen. WHO Lead Collaborating Centre of Mental Health Problems and Suicide Across Europe. results from a Suicidal Intent Scale contribute to clinical observation and add valuable information about a suicidal person’s real intention. suicidal behavior has clear verbal communication aspects. Silverman. 3Australian Institute for Suicide Research and Prevention (AISRAP). 2006). 1999. 2001. Sweden Abstract.30. 2006. Middle-aged groups scored higher for the “alcohol/drugs” component. 5National Prevention of Suicide and Mental Ill-Health (NASP) at Karolinska Institute and Stockholm County Council’s Centre for Suicide Research and Prevention. 4University of Tartu. Brisbane. Hjelmeland & Knizek.: Attempted Suicide and Suicidal Intent Crisis 2009. Valach. Beck. age. a revised version of the Pierce Suicidal Intent Scale (PSIS) was used. Wasserman. Aims: The aim of the present study was to characterize the severity of attempted suicide by extracting components of suicidal intent and analyzing levels of suicidal intent by gender. & Bongar. the © 2009 Hogrefe Publishing 87 . suicidal ideation) to the highest (serious suicide attempt and completed suicide) level of suicidality (Maris. Conclusions: In suicide-risk assessment. Raabaek Olsen. their unequivocally expressed “wish to die” was similar. Moreover. method of attempting suicide.3. Suicidal intent consists in a consciously expressed wish to be dead..3. 2004.136 cess may vary. 1974). but danger to life as assessed by interviewers was not. Vol.M. A comparable scale. 1974). is not a suicide-risk scale as such. Keywords: suicide attempt. 2001. Kairi Kõlves1. Methods: Data on suicide attempters (N = 469) were collected in Estonia using WHO SUPRE-MISS methodology. Previous research has been controversial and the need for further evidence has been pointed out. Sisask et al. Hjelmeland & Hawton. Estonia. Hjelmeland. Schuyler.5 1 Estonian-Swedish Mental Health and Suicidology Institute. the Beck Suicide Intent Scale (BSIS). Suicidal intent has been defined as the seriousness or intensity of a person’s wish to terminate his or her life (Beck. To measure suicidal intent. gender and age differences Introduction Suicidal intent is an essential component of any definition of suicide and suicidal behavior. 2001).

31. 161 © 2009 Hogrefe Publishing (34. affective disorders (F30–F39). was devised to measure the severity of suicidal intent among suicide attempters (Pierce.1).7 13.0 Total N 178 114 83 62 32 469 % 38.092. age. The aim of the present study was to characterize the severity of attempted suicide by extracting the components of suicidal intent and analyzing levels of suicidal intent by gender. The methodology of SUPRE-MISS was elaborated by a WHO expert group and adapted to local conditions (Fleischmann et al.3 8. Hjelmeland & Hawton. The internal consistency of PSIS was good (Cronbach’s α = 0.1 16.77). Those who agreed filled in a consent form. Hjelmeland et al. 2000). and variables indicating the severity of attempted suicide. Three research subjects with three or more missing PSIS responses were excluded from the final analysis. Sisask et al. Psychiatric diagnoses of 54 suicide attempters interviewed by psychologists were missing.. Its main objective was to reduce the mortality and morbidity associated with suicidal behavior.8) for males and 33.8 18.0).6 years (SD ± 14. a revised version of the original Pierce Suicidal Intent Scale (PSIS) was used (Pierce. To characterize the severity of attempted suicide. the results of various studies have been controversial and the need for further evidence on this issue. and one of the participating centers was Estonia (Tallinn).0 Females N 118 64 57 44 25 308 % 38. p = . For measuring suicidal intent. t = –1.3 100. p = . Psychiatric diagnoses were categorized as: None. The study was conducted on five continents. method of attempting suicide. Interviewers coded psychiatric disorders and method of attempting suicide according to the ICD-10.2 (SD ± 15. Vol.222. The suicide attempters’ mean age was 32.2. 30(3):136–143 88 . sharp objects (X78).. Among the suicide attempters enrolled. focusing particularly on nonfatal suicidal behavior and gender-age differences.: Attempted Suicide and Suicidal Intent 137 Table 1. WHO. The difference in mean ages of the enrolled and nonenrolled suicide-attempter groups was not statistically significant. The group with missing diagnoses did not differ from the other subjects in terms of gender.8 100. 2006. The research subjects were 469 suicide attempters. the more severe the suicide attempt. p = . In Estonia.3 17.M. 2004. but the outcome was merely a modification. p = .0 24. or other. suicide attempters were divided into five age groups (Table 1).7.1 11. and structured in-depth interviews were conducted as soon as their medical condition had stabilized. Although some aspects and meanings of suicidal intent have been studied. χ² = 9. 1977).1 100. Method of attempting suicide was categorized as: poisoning (X60– X69).5 (SD ± 11. 2005.002. The suicide attempters enrolled constituted 53% of all suicide attempters seen at the emergency department during the study period. schizophrenia (F20–F29). χ² = 2.4. The scale consisted of 12 questions and the possible total score ranged from 0 to 24: the higher the score. 1977. Material and Methods In 2000 the World Health Organization (WHO) launched the worldwide intervention study on suicidal behavior SUPRE-MISS (Suicide Prevention – Multisite Intervention Study on Suicidal Behaviors). 2002). For analysis.8.0 Pierce Suicidal Intent Scale (PSIS).7%) females.5 14. acute stress reaction (F43. Description of suicide attempters by gender and by age groups Males Age group 15–24 25–34 35–44 45–54 55+ Total N 60 50 26 18 7 161 % 37. df = 1.7. df = 1.3%) males and 308 (65. The Tallinn Medical Research Ethics Committee approved the Estonian study.698. t = 0.3 31.1) for females. p = . The difference in mean age between males and females was statistically nonsignificant. Two subjects with two missing responses and 16 subjects with one missing response were included in the analysis. duration of hospitalization after the suicide attempt. All suicide attempters identified by medical staff in the emergency-care settings of the Northern Estonian Regional Hospital between December 2001 and January 2004 were invited to participate in the study. The interviewers were clinically experienced specialists (psychiatrists and psychologists). and interviewers’ assessment regarding the physical consequences of and danger to life entailed by the suicide attempt. WHO. For analysis. Psychiatric diagnoses and method of attempting suicide were divided into categories for analysis. the following time periods were Crisis 2009. the following variables were chosen for analysis: psychiatric disorders. 2002).2 4.2 6.480.3 20. the study was conducted by the EstonianSwedish Mental Health and Suicidology Institute (ERSI). Pierce’s intention was to design and test a more objective scale for measuring suicidal intent than the BSIS. females were slightly overrepresented. Duration of hospitalization after the suicide attempt was calculated according to the date and time of admission and discharge from the hospital. and other (hard) methods. t = 0. has been pointed out (Andriessen. or mean age.

160 .138 M.6) 35–44 (SD) 8. 4–7 days. Based on ratings for these factors. and these increased with age (Table 3). suicide attempters.2) 4.5 –1.4 (± 2.052 . and PSIS components. but no danger to life. Analysis by age groups.7) 55+ (SD) 9.5 0.3) 1.053 –.6) Gender Males (SD) 8.613 .5 (± 4.264 .4) 1. Circumstances.4 (± 0.129 .4 (± 0.3 (± 0.9) 3.6) 25–34 (SD) 8.461 .5) 3.1 (± 1.123 .320 . Differences between mean scores were calculated using the t-test for gender and analysis of variance (ANOVA) for age groups and other variables.409 . Arrangements.430 Age Group 15–24 (SD) 7.5 (± 2.519 .9 5.701 .0) 3.7 (± 4.065 . comprised variables concerning the intensity of the suicide attempter’s expectations of lethal outcome and opinion about the lethality of the method chosen.0) 0. revealed statistically significant differences in mean total scores of suicidal intent.05.6) 3. Statistical analysis was performed using the SPSS (version 14.2 (± 2.200 .167 .9) 0. 30(3):136–143 Results The PSIS variables were categorized as four factors that described 62.853 .7) 1.25 chosen: 1 day.3 (± 4.5) 3.1) 0.060 .756 .042 –.8 p value .0) 0.2 (± 1.4 (± 2.0) 3. 2 days.1 (± 1. The third.3) 1.087 . over 7 days. age. © 2009 Hogrefe Publishing 89 . the procedure of principal components with varimax rotation was used. by gender and age group Total (SD) Total score of PSIS Wish to die (F1) Arrangements (F2) Circumstances (F3) Alcohol/drugs (F4) 8.8 –0. To extract the factors of the PSIS.5) F 4.: Attempted Suicide and Suicidal Intent Table 2.001 .0 (± 1.1) 0.649 .5 2. (2) medical attention/surgery required.0 (± 4.6) 3.2 (± 1.6) 3. Crisis 2009.073 .251 .5 (± 0.4 (± 0.5) 3.045 .289 . no medical treatment required. Mean scores on Pierce Suicidal Intent Scale (PSIS) and its components (factors).268 .0) 0.2) 4.5 (± 2.6) Females t-test (SD) 8.9) 0.095 .0 (± 4.075 . had/has danger to life. Sisask et al.876 .002 .110 –.4 (± 2.6 2.0) 3.1% of the total variance (Table 2).2 –0. Finally.057 .5) 4.021 .5 (± 0.6) –0.231 .1 (± 1. new scores characterizing the components of suicidal intent were calculated.0 (± 2. the interviewers were asked to choose an answer regarding the physical consequences and the danger to life for the attempted suicide as given in the interview form. Wish to Die.0) program.3 (± 1.4 (± 4.2 (± 1.105 Factor loadings . referred to verbal and nonverbal suicidal communication before the suicide attempt.1 (± 1. Statistical methods were selected in accordance with the nature of the variables.7) 45–54 (SD) 10.2 (± 1.290 .7 0.001 .165 –.5 (± 2. Vol.0 (± 1.740 . There were no statistically significant gender differences in mean total scores for suicidal intent.1) 3. The fourth.0 (± 4.112 .021 <.241 –.8 p values .1) 0. 3 days. The level of statistical significance was set at p = . Scores in terms of single PSIS components were calculated on the basis of variables combined as a single factor.714 .2 (± 4.145 .2 (± 2.136 .3 (± 2. Factor analysis (principal component analysis with varimax rotation) of Pierce Suicidal Intent Scale (PSIS) filled in after suicide attempt Components (factors) Wish to die (F1) Variables Stated intent Purpose of the act Predictable outcome Arrangements (F2) Final acts in anticipation Preparations Suicide note Communication Circumstances (F3) Isolation Timing Precautions against rescue Acting to gain help Alcohol/drugs (F4) Relation with alcohol and drugs .152 .145 . The first factor.2 (± 2.884 Table 3.267 .402 .762 –.156 . determined the possibility of intervention and prevention of fatal outcome.4) 1. (3) medical attention/surgery required.4 (± 0.694 . The possible answers were: (1) no significant physical harm. Alcohol/Drugs. The second factor.5 (± 2.8) 4.886 .2) 1. Spearman’s rank correlation coefficient was calculated to examine the relationships between gender.1) 3.631 .0 (± 2.2 (± 0. specified whether the person had consumed alcohol or drugs before the suicide attempt and whether such substances were used as facilitating means.7) 1. on the other hand.5) 1.

Mean scores for Wish to Die showed no age-group differences.9 (± 4. 30(3):136–143 90 .2) 10.4) 6. Mean scores on Pierce Suicidal Intent Scale (PSIS).001 < .056 Spearman’s rank correlation coefficient significant at . **according to interviewer’s assessment.6) 6.05 level. no medical treatment required Medical attention required.7) 8.027 .2 (± 3.9 (± 4.9) 7. Mean scores for suicidal intent were highest among suicide attempters who used poisoning as their method of attempting suicide.1 (± 4. correlation with gender and age Gender Pierce Suicidal Intent Scale (PSIS) Wish to die (F1) Arrangements (F2) Circumstances (F3) . and duration of hospitalization after the suicide attempt (Table 5).0 (± 2. while those with an acute stress reaction or other diagnosis. and Alcohol/Drugs (Table 3).M. see Table 4). had a lower level of suicidal intent.1 (± 4. suicide attempters. For the age groups. Discussion Components of Suicidal Intent As extracted in our study. © 2009 Hogrefe Publishing PSIS score (SD) F 3 6. or who had no diagnosis.9) 6. Pierce Suicidal Intent Scale (PSIS) and its components (factors) among suicide attempters. Suicide attempters with serious psychiatric diagnoses (affective disorders or schizophrenia) had higher mean scores for suicidal intent.9 (± 4. Sisask et al. These four were consciously expressed purpose and opin- Table 5. There were no significant differences in mean scores between the groups in terms of physical consequences and danger to life.4) 6. followed by those who used other (hard) methods and self-harm by sharp objects. Scores for Arrangements and Circumstances rose with age. method of attempting suicide.050 .1) 7.2 (± 4.4) 8.130* .0) 8.2 (± 4.0) Schizophrenia (F20-F29) Other Method of suicide attempt* Poisoning (X60–X69) Sharp objects (X78) Other (hard) methods Duration of hospitalization after suicide attempt 1 day 2 days 3 days 4–7 days over 7 days Physical consequences and danger to life** No significant physical harm.4 (± 4. as assessed by the interviewers (Table 5).8 6.: Attempted Suicide and Suicidal Intent 139 Table 4. had danger to life *According to ICD-10 codes. there were no statistically significant gender differences in terms of single components. Positive correlations between age and suicidal intent were statistically significant in terms of total scores for suicidal intent and the scores of its two components (Arrangements and Circumstances.023 .164* . As for the mean total score.0) 9.172* Alcohol/drugs (F4) –.9) 8.7 (± 3. differences in the mean scores of the following components were statistically significant: Arrangements.066 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+). but no danger to life Medical attention required.7 p value 242 87 43 37 378 50 38 136 51 60 92 123 14 267 185 < .2) 8.048 .001 .001 < .7) 0.4 (± 4.2 (± 4. for variables characterizing severity of suicide attempt N Psychiatric disorders* None Affective disorders (F30-F39) Acute stress reaction (F43.442 Crisis 2009.6 (± 4.2 6.2) 8. Mean scores for suicidal intent showed statistically significant differences with respect to the following variables characterizing the severity of attempted suicide: psychiatric diagnosis.8 (± 4. Circumstances.027 . Vol. the four different components of suicidal intent were very clearly differentiated on the PSIS. Correlation analysis provided no evidence of relationship between gender and suicidal intent.5 (± 3. Suicide attempters who stayed in the hospital for 3 days after the suicide attempt had higher mean scores for suicidal intent than those whose hospital stays were shorter or longer.5) 7.4 8.

termed Arrangements. Kõlves. Previous research on suicidal intent has yielded different results: Some have shown higher scores among males (Harriss. Hawton. long-term preparations and suicidal communication. 1995). It must be borne in mind that in the present study the component of Alcohol/Drugs © 2009 Hogrefe Publishing Gender Differences Gender-specific investigation showed that males and females had similar levels of suicidal intent. Suicidal intent has also been found in some previous studies to be correlated with age. short-term and immediate preparations. as well. 2004). 2005). especially with a nonfatal outcome. Hawton. is frequently a communication act that is not prompted by any real wish to die. Evidently. & Wasserman. & Zahl. and the role played in the current suicide attempt by alcohol and/or drug consumption. The level of suicidal intent among suicide attempters is easily measurable. Hjelmeland.. despite epidemiological gender differences. 80% of suicides are committed by men (Värnik. some generalizations can be made. However. Sisask et al. Amin. Harriss et al. & Wasserman (2006). The factor known as Alcohol/Drugs in the present study was distinct from factors in other studies. & Nordvik. It has been argued that male suicide attempts are more likely to be “failed” suicides. Age Differences The results of the present study showed that the level of suicidal intent rose with age. Niméus. people who commit suicide and those who make serious suicide attempts form two overlapping populations that are far more alike than different (Beautrais. expressed as Alcohol/Drugs. such as suicidal intent.. owing to methodological considerations. 2001. 2001). The results of our study corroborated the studies that had found no gender differences in suicidal intent. i. In Estonia. Hjelmeland & Hawton. Two broadly common factors. 2004). 1961). 2002. significant gender differences have been observed. and the number of factors extracted varies from two to four. (2003) carried out a review of the literature and linked it to their own study. middle-aged men are the highest risk group for alcohol abuse and dependence. 2003). Although current and prior studies are not directly comparable. Haw. Knizek. 2000). Tooding. The role of alcohol or drugs in facilitating suicide attempts was largest among the middle age groups. Hjelmeland & Hawton. 2005. Another component of suicidal intent that was not found to increase with age was Alcohol/Drugs.. Dyer & Kreitman. Conwell. and these aspects also characterize the level of suicidal intent of suicide attempters in the present study. 30(3):136–143 91 . referred to differently in other studies. 2005). & Cox. & Townsend. Scores for this component might be expected to rise with age. 1984. & Mattar. In Europe the average male-to-female suicide ratio is 4:1 and the male-tofemale attempted-suicide ratio is 1:1.5 (Schmidtke et al. Beskow. To the best of our knowledge.. while female suicide attempts may more frequently stem from factors other than a desire to commit suicide. although men chose more violent methods (Denning et al. Alsén. 2004. Diaz et al. known as Circumstances. 2005). 2003. Värnik. 1996). King. 2000. such as a wish to communicate distress and the need for help (Hjelmeland et al. Houston. 2001). The two components characterizing the preparations before a suicide attempt (Arrangements and Circumstances) showed that older people prepared their suicide attempt more carefully and planned it in greater detail.. among suicide victims in Estonia. As stated in a previous study. but there are also studies showing higher scores among females (Hamdi. The importance of direct and indirect. but the level of suicidal intent of persons who have committed suicide remains mostly unknown. although factor analyses of the BSIS have been published. There is also a 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.140 M. Vol. 1984. Wasserman. Analysis of the age variable in current research showed that suicide attempts are often of a communicative nature among younger people. what patients say should have implications when intervention and follow-up are considered (Hjelmeland. since this was true of total scores for suicidal intent. & Träskman-Bendz. Based on these differences. In the epidemiology of suicidal behavior. & Waern.: Attempted Suicide and Suicidal Intent ion about potential lethality of the act. in the literature termed a “cry for help” (Farberow & Shneidman. some studies have found that actual intent does not vary greatly with age (Haw et al. there has been no previous research on a PSIS factor structure. According to Kõlves. 2000). One surprising finding was the similarity across age groups of the mean score for the Wish to Die component.e. One study measuring the suicidal intent of people who died by suicide showed no gender differences in scores for suicidal intent. Suicidal behavior. All these components are important indicators in characterizing the nuances of the suicidal process before the suicide attempt.. verbal and nonverbal communication in the development of the suicidal process has been recognized before (Lester. it would be plausible to assume that gender may play an important role in other aspects of Crisis 2009. suicidal behavior. were expected lethality (described in the present study as the Wish to Die) and planning (Arrangements and Circumstances in the present study). we must accept the fact that. 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. older people have higher scores for suicidal intent (Dyer & Kreitman. termed a Wish to Die. while women carry out 61% of suicide attempts (Sisask. 1991) or finding no gender differences (Denning. 2002).

Suominen. Sisask et al. Suicide attempters with serious psychiatric conditions. the suicidal-intent level of suicide attempters using poisoning has been shown to be higher than that of others. information about suicidal intent is still valuable in clinical suicide-risk assessment (Harriss & Hawton. 30(3):136–143 92 . but also depend on broader background factors. This is the period needed © 2009 Hogrefe Publishing for stabilization of the suicide attempter’s condition. Nevertheless. All in all. 1996. developed for research purposes. Brown. 2005). since there are indications that any question in a Suicidal 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.” “deliberate selfharm”). and results should. 2005) and the results of the present study did. they are nonetheless at high risk for making fatal suicide attempts (Nielsen. confirm the role of psychiatric disorders in the suicidal process. given its inability to reflect the dynamic nature of suicidal behavior (Lyons. 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 the physical consequences. Controversial results from different studies can probably also be ascribed to disparate ways of measuring suicidal intent. 2002. duration of hospitalization. & Merritt. 2000). 2001). but increased with age. But although these patients may lack a strong wish to die. Methodologically uniform cross-cultural comparison on this issue would be most welcome. interviewer’s assessment on lethality) provide some hints for discussion around the construct validity of the PSIS. 1993). be interpreted with care. Suicide attempters spending less or more time in hospital had lower mean scores for suicidal intent. Goldney. indeed. The first problem associated with comparison is the potential variation in definitions and criteria used for selecting research subjects (“attempted suicide. This was corroborated by the present study. such as affective disorders (mainly depression) and schizophrenia. Males and females were also similar with respect to individual components of suicidal intent.” who behave in self-destructive ways without being highly suicidal (Skegg. Methodological Considerations It is questionable whether the results of the present study are comparable with other results from different studies on suicidal intent. Isometsa. since in every single case the physical consequences are not only the outcome of the current suicide attempt. and danger to life of the suicide attempt.. Conclusions In conclusion. previous research has suggested that the level of suicidal intent appears to be a powerful predictor of eventual suicide after attempted suicide (Hjelmeland. Psychiatric disorders have been clearly linked to suicidal behavior (Joiner. Ostamo. Other variables included in the analysis as possible characteristics of the severity of suicide attempt (psychiatric disorders. Suicide attempters who stay in the hospital for long periods probably suffer from complications they did not initially mean to provoke. Vol. Suicide attempters are probably incapable of adequately assessing the potential lethality of drugs or substances they ingest. need for medical attention/treatment. In terms of the duration of hospitalization after the suicide attempt. Price. scores for more equivocal communication (components termed Arrangements and Circumstances) increased with age. such as the general health and fitness of the suicide attempter. 2004). Although a higher level of suicidal intent at the time of the suicide attempt has been found to be a risk factor for possible future suicide. Fisher. suicidal intent was strongest among those spending 3 days in the hospital. It is known from a previous study that alcohol-dependent suicide attempters obtain relatively low scores on the Suicidal Intent Scale. These persons are most likely to be “habitual self-harmers. conclusions about the severity of attempted suicide based on the duration of hospitalization should be drawn carefully. therefore. & Lonnqvist. had higher levels of suicidal intent than others. Applicability in Clinical Practice The question has arisen whether a tool like the PSIS. & Brahe. Nevertheless. Embling. four components characterizing the nuances of the suicidal process before attempted suicide were very clearly differentiated. it has been admitted that a Suicidal Intent Scale cannot forecast which specific patients will die by suicide. Although scores for the unequivocally expressed Wish to Die component were similar among all age groups. the present study demonstrated that. 2000).: Attempted Suicide and Suicidal Intent 141 does not differentiate between alcohol abusers and nonabusers. Niméus et al. & Smith.” “parasuicide. 2000). method of attempting suicide.M. should be used in the same way in practice. Although poisoning has been classified as a “soft” suicide method compared with other methods (Spicer & Miller. & Wingate. 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. However. or the availability and effectiveness of healthcare services. but no more. The level of suicidal intent was not gender-dependent. Stenager.” “serious suicide attempt. The AlcoCrisis 2009. 2005). The lowest level of suicidal intent was found among suicide attempters who used sharp objects for self-harm. this statement does not disparage the interviewers’ entire contribution. in the Pierce Suicidal Intent Scale (PSIS). It is very likely that persons committing less severe suicide attempts spend up to 2 days in the hospital. and this may explain their lower level of suicidal intent.

Hjelmeland. Botega. K. E. (1991). Kerkhof. (2000). T. J. European Archives of Psychiatry and Clinical Neuroscience.. Chennai. Acknowledgments This paper is based on the data and experience obtained during the authors’ participation in the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS). De Leo. 17. E. J. the Swedish National and Stockholm County Council’s Centre for Suicide Research and Prevention of Mental IllHealth (NASP) at the Institute for Psychosocial Medicine (IPM). 186. B. Raabaek Olsen. 86. K. Verbally expressed intentions of parasuicide: II..T. & Shneidman. Schmidtke (Eds. D. Hawton. Journal of Affective Disorders. (1984). M. The cry for help.. Harriss. 144. References Andriessen. H... K..S. British Journal of Psychiatry. and suicidal intent in parasuicide. H. 33. Diaz.T. Suicide and Life-Threatening Behavior.. L. U. C. Kovacs. De Silva.. & Townsend. V. Y. Beck.” and Project No. 343–352. (1999). 127–133. Prof. Level of suicidal intent was associated with psychiatric diagnosis.1.. (2004). On “intention” in the definition of suicide.142 M.M. Hamdi. Colombo. In the interviewers’ assessment. 533–538. Development of suicidal intent scales. 16. 47. Amin. & Mattar. Phillips. Baca-Garcia.. Göttingen: Hogrefe & Huber. (2005). (2003).. The Tallinn center obtained additional funding from the following agencies: The Estonian Health Insurance Fund... 6799. E. Journal of Consulting and Clinical Psychology. Beijing.. A. Suicides and serious suicide attempts: Crisis 2009. “The role of alcohol in the suicide process and in prevention of suicidal behavior. De Leo. N. Resnick. (2000). 225–233. Prof. Acta Psychiatrica Scandinavica. H. & Kreitman.).. Project No 1. Prof. D. Conwell.). Crisis. & A. Wasserman. K. Suicide and Life-Threatening Behavior. & D. 1467–1474. (2005). Blasco. A. L. intent. M. H. (1979). Dimensions of suicidal behavior according to patient reports. Schuyler. Crisis.. British Journal of Psychiatry. Harriss. D. 147–157). Department of Public Health Sciences. 10–14. Bertolote. H. Prediction of fatal and nonfatal repetition. Durban. Bertolote and Dr. Fleischmann. C. Dr. D. Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Lettieri (Eds. Bolhari. N. Dr. London: Martin Dunitz. 30(3):136–143 Two populations or one? Psychological Medicine. Psychological Medicine.. J. depression. The international handbook of suicide and attempted suicide. New York: Blakiston Division. “Suicide trend in Estonia during independence: What are the associations with sociopolitical.. The level of suicidal intent as measured by a Suicidal Intent Scale is valuable information on suicidal person’s true intention and could help clinical observation performed by a specialist in suicide-risk assessment. 67–78). Suicide and Life-Threatening Behavior.. method of attempting suicide..: Attempted Suicide and Suicidal Intent hol/Drugs component had higher scores among the middle age groups. A. Botega. Special gratitude belongs to Prof. Suicidal intent in deliberate self-harm and the risk of suicide: The predictive power of the Suicide Intent Scale. Vijayakumar. Tallinn. van Heeringen (Eds. Sisask. & Nimeus. H.F. Wasserman (Ed. (2006). D. Hawton & K. Bille-Brahe.. Prof D. Campinas. Bowie. Denning. 197–202. Correlates of relative lethality and suicidal intent among deliberate self-harm patients. 253. Hawton. N. & Cox. (1974).T. ML: Charles Press. General hospital management of suicide attempters.. Geneva.. A. Assessment of suicidal intention: The scale for suicide ideation. In K. Suicide: An unnecessary death (pp. & Hawton. Geneva. Karolinska Institute. (1996). M. and duration of hospitalization after suicide attempt. Hopelessness. J. M. Conceptual confusion about intentions and motives of nonfatal suicidal behavior: A © 2009 Hogrefe Publishing 93 . 837–845.A.L. Method choice. (2005). Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low. Houston. J. economic. Braquehais Conesa. Hawton. D. Dr. & Weissman. Thanks are due to Clare James for her thorough linguistic and stylistic revision of the manuscript.T.. 31. Stockholm have acted as scientific advisors. 282–288. and gender in completed suicide. 45–56). De Leo. Intentional aspects of nonfatal suicidal behavior. (1961). K.L. Verbally expressed intentions of parasuicide: I. Y. L. I. Farberow. Dyer. In A. 36.and middle-income countries. Beck. Sisask et al. 176–181.M. & Zahl. 353–364. Hjelmeland. Brisbane and Prof. E. Haw. A. A. 35. King.J. P. 83. D. Värnik. The prediction of suicide (pp.. et al. (2003). Diaz-Sastre. 7132. K. L. Fleischmann have coordinated the project at WHO Headquarters.P.. & Herman. characteristics of patients with various intentions. A list of other staff contributing to the project can be obtained from WHO. The Collaborating Investigators in this study have been (in alphabetical order): Dr. A. N. 406–411. Wasserman for suggestions concerning the focus of the present paper. Suicidal behavior: Theories and research findings (pp. Hjelmeland. (1995). there were no differences in level of suicidal intent among groups of suicide attempters categorized in terms of the physical consequences and danger to life owing to the suicide attempt. F. Tehran. A.. Vol.L.. (2001). & Knizek. C. K.L. et al. a project funded by the World Health Organization and the participating field research centers.G. (2001). Dr. D.). Hanoi.0101–0267). In D.. Bech. Beautrais. Hjelmeland. In D.. and Dr. L. the European Social Foundation (Measure 1.. D. Phillips. 60–66. Schlebusch. E. Beck. and public health indicators?”). Clinical correlates of intent in attempted suicide.J. 30. Garcia Resa. Nguyen. & Hawton. New York: Wiley. Psychometric scales in suicide risk assessment.). the Estonian Scientific Foundation (Project No.

D. E. PhD. Goldney. K. U. B.S. a master’s degree (2001). WHO. L. 1471–1483.ee © 2009 Hogrefe Publishing Crisis 2009. Spicer. and psychic factors of attempted suicide]. 275–281... M. D. Bille-Brahe.S. Price.B. (2000). Suicide and suicide attempts in Europe. & Lonnqvist. Suominen. Niméus. Crisis. 36.. Merike Sisask Õie 39 Tallinn 11615 Estonia Tel.. 23. 90.. & Waern. Embling. (2002). H... She holds a doctoral degree in gerontopsychiatry from Leningrad Behterev’s Psycho-Neurological Scientific Research Institute (1973) and a doctoral degree in psychiatry from the Karolinska Institute (1997). Crisis. The communicative aspect of nonfatal suicidal behavior – Are there gender differences? Crisis. London: Martin Dunitz. Acta Psychiatrica Scandinavica. L. (2002)./Fax +372 651 6550 E-mail merike..... De Leo. A.. & Miller. Värnik. 172–178. 22.M. M... Sisask. B. Kõlves. Suicidal behavior in Europe (pp. British Journal of Psychiatry. 30. K. Cambridge/Göttingen: Hogrefe & Huber. Bille-Brahe. 15–28). T. Kerkhof. She is presently Research Fellow at the Australian Institute for Suicide Research and Prevention (AISRAP. & Bongar. The role of alcohol in suicide: A case-control psychological autopsy study. suicidal intent. D. (2000). Wasserman (Ed. K. M.sisask@neti.. D. Michel. British Medical Journal. (1996). L. 14. Alsén.S. Kairi Kõlves. Suitsidaalsus ühiskonnas ning suitsiidikatse sotsiaal-demograafilised. & Träskman-Bendz. H. PhD. 1885–1891. The suicidal process in suicides among young people. Tooding. (2000). Hjelmeland. A cross-cultural study of suicide intent in parasuicide patients.L. Airi Värnik. Nonfatal suicidal behavior as a communication.E. U.M... 13–27). Lester. Schmidtke. L. A... 287–314. 178–186... Kõlves. Wasserman. Watson.M. P.. (2000). 30(3):136–143 94 . Lyons. V. Kerkhof (Eds. J... Executive Director and Researcher at the Estonian-Swedish Mental Health and Suicidology Institute (ERSI). 176–177. H. 35–42. Suicide and Life-Threatening Behavior. is founder and Director of the EstonianSwedish Mental Health and Suicidology Institute (ERSI).. 130. (2005). E.. The measurement of suicidal ideation. & Waeber. T. Archives of Suicide Research.). Vol. Lancet. Suicidal intent in self-injury... C. R. R. M. 295–303. Schmidtke. R.F. 8. American Journal of Public Health. Kerkhof. About the authors Merike Sisask. Knizek. High suicidal intent scores indicate future suicide. & Wingate. U. and alcohol. Comprehensive textbook of suicidology. Löhr. D. MD. MSc. M. Psychological Medicine. Pierce. Annual Review of Psychology. & Nordvik. Weinacker. Suicide risk assessment: A review of procedures. She also holds a master’s degree in public health (2005) and is presently a PhD student in sociology at Tallinn University (2006–2010). J. D.. Multisite Intervention Study on Suicidal Behaviors SUPRE-MISS: Protocol of SUPRE-MISS.. Joiner.R. K. A. A. Suicide: An unnecessary death (pp. 6. B. (2004). Jr. (2001). J. Berman. Isometsa. Skegg. 15.M. Maris.W.W.. Suicide acts in eight states: Incidence and case fatality rates by demographics and method. medical. U..: Attempted Suicide and Suicidal Intent 143 discussion of terms employed in the literature of suicidology. (2005). and a doctoral degree (2006) in sociology from the University of Tartu.. The psychology and neurobiology of suicidal behavior. Värnik.. 12–14. Attempted suicide. In D. De Leo. Crisis. A. (2001). (2001). New York: Guilford. C. & Wasserman. (2004). Nordvik. meditsiinilised ja psüühilised mõjurid [Suicidality in the community and sociodemographic. BMC Psychiatry. 2008/2009). 211–219. 144–155.R. H. Crisis. (2006). Tartu: Tartu Ülikool. Archives of Suicide Research. L.. 377–385.. She holds a bachelor’s degree (1999). 11. & Brahe. (1993). Ostamo.). C. Bille-Brahe. D. Runeson. 93. Understanding deliberate self-harm: The patients’ views. 56. & Smith. Stenager. (2005). 22. 5. 330. et al. professor at Tallinn University. Hjelmeland. Level of suicidal intent predicts overall mortality and suicide after attempted suicide: A 12-year follow-up study. J.L.. 923–930. 32–38. Suicide among Russians in Estonia: Database study before and after independence. J. B.. K. In A. is Researcher at the the Estonian-Swedish Mental Health and Suicidology Institute (ERSI). 49–51. Beskow. Self-harm. 4. Tervishoiu Instituut. D. & Merritt. A. Accident and Emergency Nursing. 366. D. Sisask et al.S. A stress-vulnerability model and the development of the suicidal process. (1994). Silverman. Nielsen. Fisher. Lonnqvist. has a bachelor’s degree in law (1991) and has worked as a psychological counselor (2003). Geneva: WHO. A.. (1977). & Wasserman. Brown. Valach. De Leo. A.. & A. (2002). (2005). et al. and a visiting professor at the the Karolinska Institute as well as a full member of the International Academy of Suicide Research. S. She is an expert on forensic psychiatry..

IV .

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

Jose M. 2008. the effect was exceptional both for religious denomination (OR ¼ 5. religiosity. Alexandra Fleischmann. 44 97 . Keywords attempted suicide. research findings on the impact of religiosity on suicidal behaviors has tended to favor the idea of inverse association and protective effect. Botega. organizational religiosity. Vijayakumar. However. subjective religiosity (considering him=herself as religious person) may serve as a protective factor against non-fatal suicidal behavior in some cultures.5). Although exceptional and controversial findings on this issue cannot be denied. less work has been done in developing countries. The present study focuses on three dimensions of religion: religious denomination. within the Eastern cultural system or in more secularized societies (Colucci & Martin. 2008. and symbols designed to facilitate closeness to the sacred or transcendent.Archives of Suicide Research. Airi Varnik. Organizational religiosity gave controversial results. Furthermore.. practices. Kairi Kolves. and subjective religiosity. rituals. Pirkis et al. Islamic Republic of Iran (OR ¼ 0. cross-cultural study. In South Africa. 14:44–55.5) and subjective religiosity in four countries: Brazil (OR ¼ 0. 2010 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10. In particular. No effects were found in India and Vietnam. Koenig and colleagues (2001) have defined religion as an organized system of beliefs. case-control study. most of the studies performed so far are hardly comparable.6). The majority of studies have been ecological by design and relatively few individual-level findings have been reported.7). religion is a wide concept that is comprised of different dimensions.1080/13811110903479052 Is Religiosity a Protective Factor Against Attempted Suicide: A Cross-Cultural Case-Control Study Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 ´ Merike Sisask. and Sri Lanka (OR ¼ 0. and Danuta Wasserman This cross-cultural study investigates whether religiosity assessed in three dimensions has a protective effect against attempted suicide.2). Bertolote.9) and subjective religiosity (OR ¼ 2. 2005). Estonia (OR ¼ 0. Community controls (n ¼ 5484) were more likely than suicide attempters (n ¼ 2819) to report religious denomination in Estonia (OR ¼ 0. Lakshmi Vijayakumar. John. Due to conceptual and methodological discrepancies. Stack & Kposowa. Neury J.4). while the majority of studies have been conducted in developed countries and based predominantly on US data. WHO SUPRE-MISS INTRODUCTION Since Durkheim (1897=2002). a higher level of religiosity indicates a lower level of suicidality. ¨ ˜ Jafar Bolhari.

Moreira-Almeida. A question widely used to investigate the level of religious involvement. 2006. individual and inwardly directed than religiosity (Koenig. can be considered protective against suicide (Breault. Botega et al. 2000). and subjective religiosity—could serve as a protective factor against attempted suicide from a cross-cultural perspective. Conwell et al. 1998).... organizational religiosity. The aim of the current study was to investigate whether religiosity assessed in these dimensions—religious denomination. but frequent participation in religious activities did. 2006). 1983).. is closely inversely associated with suicidal behaviors (da Silva. 1983). Faria. 1988).. House. 2006). partially due to the growing convergence of Catholicism and Protestantism (Stack. Grunebaum et al. Although several studies have supported Durkheim’s classical findings (Dervic. 2006). 1996. Church.. Neto. Conwell. 2002). which suggests that something more specifically intrinsic in religious identity might be responsible for decreasing suicide risk (Nisbet. Musick. in turn. In postmodern societies. Another study showed that visiting or talking with friends or relatives did not reduce the likelihood of suicide. others doubt the effect of religious denomination as a measure of religious integration and regulation in the contemporary world (MoreiraAlmeida.. how often someone attends religious meetings) is one of the most commonly used questions to investigate the level of religious involvement (Koenig. & Koenig. 1897=2002). Durkheim illustrated the protective effect provided by religious denomination via social integration and regulation with the lower suicide rates reported in Catholic countries compared with Protestant countries (Durkheim. de Oliveira. exactly which elements of religious participation reduce the risk of suicide cannot be discerned.. Oquendo. 2004).M. & Williams. Victora. The dimension of subjective religiosity leads us closer to the concept of spirituality. Conner et al. 2006). 2002. Kelleher. Several studies have revealed that religious commitment. 1986.e. 2001). Stack & Lester. Siegrist. de Graaf. & Larson. & Koenig. Regardless of denomination. 2004. 1991). Meneghel et al. A comparison between Islam and Christianity has shown that the strong degree of integration between individual and society developed by followers of the Islamic tradition has a reducing effect on suicide rate (Bertolote & Fleischmann. expressed in church attendance. Pescosolido and Georgianna (1989) claimed that either religious or other network ties have both integrative and regulative aspects and act therefore as important sources of social and emotional support. Oquendo. However. Duberstein. Corcoran et al. mosque or other important religious attendance (i. which has been described as less formal and organized and more subjective. Victora. 1986) and the presence or absence of religious denomination may be more useful than the evaluation of an association between specific religious denominations and suicidal behaviors (Dervic. & Koenig. Grunebaum et al. 2005. Regardless of type. 2004. 2006. McCullough.. 2004. Stack. Meneghel et al. Neto. Spirituality outside the formal religion has found to start to flourish in the postmodern era (Hay. 2004. Chambers. Duberstein. 1998. and the importance of religion in someone’s life. Neto. Simpson & Conklin. actual church attendance can be used as an indirect indicator of religious commitment and. & Vollebergh. Neeleman. Sisask et al. religion in general may provide protection from suicide (Breault. Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 ARCHIVES OF SUICIDE RESEARCH 45 98 . personal beliefs are at least as relevant as integration in religious institutions when explaining individual and group behaviors (Neeleman. is subjective religiosity (Moreira-Almeida. Faria.

psychologists. Vietnam (Hanoi). Islamic Republic of Iran (Karaj). These community members also served as controls for the suicide attempters.and middle-income countries around the world: Brazil (Campinas).. thoughts) during their lifetime. at least 500 randomly selected community members from the general population were interviewed for the community survey. South Africa (Durban).Religiosity Against Attempted Suicide METHOD General Description Data Collection Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 In 2000. the suicide attempters were asked to fill in a consent form and were thereafter interviewed by clinically experienced and specially trained psychiatrists. medical doctors. Fleischmann. Fleischmann. medical staff identified suicide attempters in one or more emergency settings within a catchment area that had a population of at least 250. 2005). De Leo et al. the World Health Organization (WHO) launched the worldwide intervention study on suicidal behavior SUPRE-MISS (Suicide Prevention—Multisite Intervention Study on Suicidal Behaviors) with the main objective being to reduce the mortality and morbidity associated with suicidal behaviors. The study was conducted in seven culturally diverse low. Once medically stable. 2819 suicide attempters and 5484 controls were interviewed.. psychologists or psychiatric nurses. 2002). medical doctors. The interviewers were specially trained nurses. Sri Lanka (Colombo). The detailed description of the study and the characteristics of the suicide attempters as well as the community survey have been previously presented elsewhere (Bertolote. TABLE 1. Estonia (Tallinn). In total. plans. between 2002 and 2004. Bertolote. India (Chennai). and public health professionals. 2005. à Suicidal–persons reporting suicidal behavior (attempts. medical students. In the same catchment areas. Number of Suicide Attempters and Control Group Included in the Study Control group Suicide attempters Brazil Estonia India Islamic Republic of Iran South Africa Sri Lanka Vietnam Total 162 332 680 632 570 300 143 2819 Non-suicidal 420 433 486 433 371 632 2079 4854 Suicidalà 96 67 14 71 129 52 201 630 Total 516 500 500 504 500 684 2280 5484 Note. In each of the participating sites. Detailed numbers of the research subjects by participating sites are given in Table 1. De Leo et al. The methodology of SUPREMISS was elaborated by a WHO expert group and adapted to the local conditions of each participating site (WHO. The research protocol was approved by the relevant ethics committee in each site. 46 VOLUME 14  NUMBER 1  2010 99 .000. family health workers. All participants provided informed consent.

divorced= separated) 4. the religious denomination was recoded to ‘‘no’’ and ‘‘yes’’ (for any denomination) answers. Bernasco. 2000). yes. Sisask et al. the controls were asked the following questions: 1. Instruments Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 The questionnaire for suicide attempters. non-university higher education. ‘‘weekly’’. armed service. frequency of going to church was recoded to ‘‘never’’. How often do you go to church (or other place of worship)? Response choices were: At least once a week. Bille-Brahe et al. Hindu. Protestant. housewife=homemaker) 5. Binary and multinomial logistic regression analyses were performed to calculate odds ratios (OR) with a 95% confidence interval (95% CI).M. To assess suicidal behavior during their life-time. Marital status: living with partner (recoded from: married or living with permanent partner) and living without partner (recoded from: single. Buddhist. employed. ARCHIVES OF SUICIDE RESEARCH 47 100 . the original values ‘‘no’’ and ‘‘yes’’ were used. 3. almost never. provide protection against attempted suicide and adjust thereby the effect of religiosity less significant (Stack. Statistical Analysis Statistical analysis was performed with the SPSS program (version 14. Have you ever made a plan for committing suicide? 3. and ‘‘yearly’’. Employment status: economically active (recoded from: full-time employed. university education) and low educational status (recoded from: none. based on the European parasuicide study interview schedule (EPSIS) of the WHO=EURO multicenter study on suicidal behavior. ‘‘monthly’’. a control was classified as suicidal and excluded from logistic regression analysis as improper for the control group (Table 1). part-time employed. Jewish. 2–3 times a year. Age in years 2. Differences between suicide attempters and the control group were evaluated by chi-square tests. For logistic regression analysis. and for subjective religiosity. WHO. but on sick leave. Educational status: high educational status (recoded from: secondary education. translated and pilot-tested in each site (Kerkhof. temporary work) and economically inactive (recoded from: unemployed. 2. full-time student. What is your religious denomination? Response choices were: none. In the current study.0). 2002). Catholic. about once a year.. Sociodemographic variables (age. 1999. retired. Gender: males and females 3. These included in the regression analysis to statistically control them: 1. primary education). Both the suicide attempters and controls were asked the following religionrelated questions: 1. disabled. Have you ever seriously thought about committing suicide? 2. the following sociodemographic control variables were available within the SUPRE-MISS instruments. Do you consider yourself to be a religious person? Response choices were: no. Greek orthodox. A recurring problem in sociological work is the confounding effect of several characteristics. once a month. Have you ever attempted suicide? If the answer was yes to any of these questions. gender. permanently sick. widowed. marriage. other. which may act as buffers. and a common survey instrument for the community survey were developed. Muslim.

7 21 4.5 3 0.8 293 51.3 31 5.2 44 6.3 13 0.6 0 0 0 0 0 0 2 0.1 3 1 2 0.4 0 0 1 0.1 2 0.1 0 0 0 0 0 0 1 0.7 0 0 344 66.7 0 0 0 0 3 0.6 28 5.0 571 84.8 16 3.3 0 0 1 0.Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 TABLE 2.7 54 18.7 2 0.5 2 0.0 161 24.1 134 93.7 502 99.2 1 0.2 1 0.4 0 0 188 37.0 128 5.1 0 0 0 0 1 0.9 7 1.1 0 0 0 0 83 16.0 0 0 0 0 62 12.5 58 11.3 0 0 0 0 0 0 0 0 127 25.7 16 0.1 100 19.2 0 0 0 0 0 0 2 0.6 4 1.5 65 19.2 1 0.4 47 30.1 0 0 516 100 154 100 498 100 332 100 500 100 680 100 504 100 632 100 497 100 565 100 663 100 300 100 2277 100 144 100 101 .6 0 0 0 0 460 92.3 38 12.4 0 0 23 4.7 24 4.6 9 6.8 1 0.2 291 43.2 6 1.6 33 9.6 25 3.5 0 0 0 0 81 16.2 0 0 0 0 1 0.2 0 0 2074 91.7 74 13.8 223 67.9 171 57.6 0 0 0 0 0 0 0 0 1 0.5 0 0 0 0 68 13.6 0 0 0 0 0 0 0 0 0 0 1 0.2 116 17.6 632 100 13 2.2 43 8.7 75 48.2 0 0 1 0.5 114 20.9 243 48.0 40 1.2 14 2.3 28 5.1 84 12.1 23 14.5 31 10. Religious Denomination: Suicide Attempters (SA) in Comparison with Control Group (CG) None CG SA CG SA CG SA CG SA CG SA CG SA CG SA Protestantism Catholicism Jewish Islam Hinduism Orthodox Buddhism Other Total 48 Brazil Estonia India Islamic Republic of Iran VOLUME 14  NUMBER 1  2010 South Africa Sri Lanka Vietnam N % N % N % N % N % N % N % N % N % N % N % N % N % N % 42 8.1 0 0 2 0.4 8 5.9 0 0 24 3.

and in Vietnam (p ¼ 0. in India and Vietnam yearly visits had a protective effect and weekly or monthly visits remained statistically nonsignificant.36 0. Employment and Education 95% CI OR Lower Higher p-value 1. Marriage. ARCHIVES OF SUICIDE RESEARCH 49 102 .612 In India. various denominations without any of them prevailing in South Africa. monthly visits demonstrated risk effect and yearly visits a protective effect (Table 4).067) and among males in Brazil (p ¼ 0.001 Brazil 0.86 3.37 India Not calculable Islamic Not calculable Republic of Iran South Africa 5.71 0.852).37 Estonia 0.05. therefore the odds ratio was not calculable. Binary Logistic Regression Analysis Adjusted for Gender. India. Islam (Shi’ite) in the Islamic Republic of Iran. In Brazil and Vietnam. Controversial results came from Vietnam as weekly visits were statistically non-significant. Differences between suicide attempters and the control group in the pattern of distribution of religious denominations were significant at p < 0. where in both groups the majority of people had no religious denomination. Sri Lanka. in Estonia. in addition to a great amount of people without religious denomination.53 0. Hinduism in India. Protestantism and Orthodox. The differences were non-significant in the Islamic Republic of Iran (p ¼ 0. employment. where in both groups the main religious denomination was Islam.72 0.859).299 0.15 Sri Lanka Not calculable Vietnam 0. and Buddhism in Sri Lanka. Effect of Religious Denomination. Religious Denomination� : Suicide Attempters in Comparison with Control Group. Age. However. TABLE 3. Sisask et al.M. males and females tended to have similar patterns of distribution with two exceptions only—there were no significant differences between the suicide attempters and the control groups among females in India (p ¼ 0. Religious denomination – yes (any) versus none. The level of statistical significance was set at a ¼ 0. In total. only monthly visits served as a protective factor while weekly and yearly visits were statistically non-significant. the effect of religious denomination was statistically non-significant (Table 3).001 2.72 <0. Sri Lanka and the Islamic Republic of Iran all controls and=or suicide Note. Religious denomination was more likely to be reported by the controls than the suicide attempters in Estonia and less likely to be reported in South Africa. The frequency of attending church or another place of worship (organizational religiosity) demonstrated a distinctly protective effect in Brazil and Iran.51 0. and Subjective Religiosity Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 attempters had some kind of religious denomination. yet in South Africa and Sri Lanka. most of the people reported no religious denomination (Table 2).90 <0. RESULTS Religious Denomination The results of the study revealed a large diversity of religious denominations across participating sites.21 � 10. education) were included in the regression analysis to statistically control them. In Vietnam.197). the odds ratios were statistically non-significant. Organizational Religiosity. Brazil and South Africa. In Estonia. Predominant religions were Catholicism and Protestantism in Brazil.001 level in Estonia.

39 3. In Brazil.28 0.65 1.001 0.82 p-value <0.66 1.19 0.148 0.44 Higher 0. DISCUSSION Note.85 0.60 0. Marriage.79 0.42 1.620 0.41 0. religious context has been recognized as a major cultural factor in the determination of suicidal behaviors (Bertolote & Fleischmann.97 0.46 4. Employment and Education 95% CI OR Brazil Estonia India Islamic Republic of Iran South Africa Sri Lanka Vietnam 0.90 0.54 0.10 0.79 0.15 0.62 2.33 2. the present study is the first individual-level 50 VOLUME 14  NUMBER 1  2010 103 . Suicide Attempters in Comparison with Control Group.60 Lower 0.001 0.51 0.13 0.32 0.753 <0.46 0.23 0.77 0.002 <0. Age.001 <0.28 3.36 1.12 0.33 0.002 0.001 0.305 0.60 1.111 0. Organizational Religiosityà .958 0.52 0.001 0.15 0.30 0.Religiosity Against Attempted Suicide TABLE 4.450 0.989 Note.10 1.93 0.77 1. controls were less likely to consider themselves religious.94 0. Estonia.77 Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 2.75 1.526 0. organizational religiosity. à Subjective religiosity – considering him=herself as religious person.67 0.83 0. Binary Logistic Regression Analysis Adjusted for Gender.22 0. Age. and subjective religiosity—could serve as possible protective factors against attempted suicide.45 0.003 0.56 0. 0.56 3.42 1.001 0.276 0.51 0.54 0. Stack.71 0.78 0. Suicidal behaviors are a global public health problem and a complex phenomenon influenced by a number of mixed biological.24 1.824 0.50 0. 2002. To the best of our knowledge.190 0.85 0. Among other agents.001 (subjective religiosity) compared with suicide attempters.003 TABLE 5. à Organizational religiosity – frequency of going to church or other place of worship.51 0.62 0. Ãà Reference category—never.35 0.26 0.37 0.37 0.67 1.00 1.50 0. Suicide Attempters in Comparison with Control Group.87 0. Marriage.09 0. the Islamic Republic of Iran and Sri Lanka. Multinominal Logistic Regression AnalysisÃà adjusted for Gender.60 0.67 1.53 0.001 0.12 0.533 0.80 0. social and cultural factors. Subjective Religiosityà .17 0.24 0.64 1. psychological. controls were more likely to consider themselves to be religious The aim of this study was to find out whether different dimensions of religiosity— religious denomination.17 0.33 0.29 0.723 0. the odds ratio of subjective religiosity was statistically non-significant (Table 5). in South Africa.86 0.007 0.53 0.25 0. In India and Vietnam.45 0. Employment and Education 95% CI OR Brazil Weekly Monthly Yearly Estonia Weekly Monthly Yearly India Weekly Monthly Yearly Islamic Republic of Iran Weekly Monthly Yearly South Africa Weekly Monthly Yearly Sri Lanka Weekly Monthly Yearly Vietnam Weekly Monthly Yearly Lower Higher p-value <0.33 0. 2000).81 <0.001 0.

1998. They believe in karma. the lifetime prevalence of suicidal ideation among Protestants was lower than among Catholics. which enables the effect of religiosity on suicide attempts to be investigated from a cross-cultural perspective. as both controls and suicide attempters reported some kind of religious denomination. the Islamic Republic of Iran and Sri Lanka. Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 ARCHIVES OF SUICIDE RESEARCH 51 104 . 2006). which facilitates the idea that putting an end to one’s life is not the final step (Bolz. The Hindu religion tolerates suicide in situations when a person is considered socially dead already. and even Christianity (Lester. However. However. Pescosolido & Georgianna. as suicide victims are often seen as mentally ill (Simpson & Conklin. In a very secular country. the strength of this condemnation has varied over time and within the religions themselves. both religion and suicidal behaviors are social constructs and consequently dynamic across eras and cultures. Chambers. 1998). the Islamic Republic of Iran. Seshadri. Both Hindus and Buddhists are more ambivalent in their attitudes towards suicidal behaviors. Sri Lanka) and some were very or rather secular (Vietnam. Catholicism was more frequent among the control group than among suicide attempters and Protestantism was more frequent among suicide attempters than among controls.. Moreover. The Islamic doctrine regarding suicide is well known: persons taking their own life will be denied entry to heaven. religious denomination had no effect on suicide attempts in Brazil but it can be assumed that Protestantism could neutralize the protective effect of Catholicism. Brazil and South Africa were more ambivalent in their religiosity. Estonia). Islam is arguably much firmer about the sinfulness of suicide than Hinduism and Buddhism. all-powerful factor associated with suicidality. The prevailing religious denominations across the SUPRE-MISS sites differed to a large extent and most of the major religions in the world were represented. In India. the complexity of suicidal behaviors and the knowledge that religiosity is not the only. this is only a speculation. Corcoran et al. the results of the study cannot be interpreted without keeping in mind the reliability of self-reported information about sensitive issues. the effect of religious denomination on suicide attempts was not calculable. the Islam religion condemns on one hand and forgives on the other. Sisask et al. Christianity and Islam. This study analyzed Christianity as a whole as differentiating the effect of denominations within Christianity was not the issue of interest. Suicide is considered a sin and subsequently a crime. Within Christianity. 2000). religious denomination had no effect against attempted suicide. especially in the three monotheistic religions of Judaism. & Raj. study conducted concurrently in culturally different sites. Subsequently. In Brazil. such as Vietnam. Some sites were very religious (India. a study by Botega and colleagues (2005) found that in Brazil. 2007). suicide is condemned. A separate social construct known in the context of Islam is suicide terrorism. 2002). However. In most known religions of the world. 1988). but it is also a shameful act within the family and subsequently must be concealed (Khan & Reza. A protective effect emerged only in Estonia which is rather secular but still a predominantly Christian country.M. such as serious handicap (Tousignant. the other Christian country. Still. However. The sites differed substantially across the religiositysecularity spectrum. 1989). as suicide terrorists do not appear to be truly suicidal and belong to a subgroup of terrorist population (Townsend. the conservative church members (Catholic and Orthodox) have been the most outspoken against suicide with the sixth commandment (‘‘Thou shall not kill’’) used as the official Christian statement prohibiting suicide (Kelleher.

Religiosity Against Attempted Suicide South Africa. van der Veen. the interaction of cultures results in the blurring of cultural norms and boundaries at the individual. In the predominantly Christian Brazil and the Islamic Republic of Iran. Religious denomination is one of the most widely used measures of religion in medical research. subjective religiosity protects against completed suicide. heterogeneity and blurring of cultural norms within the site. 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. 2004). was the only site where religious denomination showed a risk effect. It may mediate health outcomes through engendering feelings of self-esteem. As mentioned above. the effect was statistically non-significant. The frequency of attending church or other place of worship in different SUPRE-MISS sites gave controversial results. self-worth and positive emotions thus providing a sense of meaning. In South Africa. fostering feelings of control and the ability to manage difficulties (Flannelly. 2003). there is a large diversity of religious denominations and this does not seem favorable in terms of providing protection against attempted suicide. Estonia. Burr. 1998). India and Vietnam. the meaning of going to church and. Nevertheless. the frequency of church attendance provided an unequivocal protective effect against attempted suicide. & McCall. In our postmodern world. To interpret these results. & Strock. & Pillay. In two sites (India and Vietnam). However. not against attempted suicide (Vijayakumar. There are a variety of ethnic groups and a greater variety of cultures within each of these groups. There is a study available which demonstrates that religious homogeneity. Limitations Downloaded By: [Tartu University Library] At: 12:53 1 February 2010 The SUPRE-MISS study was not specifically designed to study the effects 52 VOLUME 14  NUMBER 1  2010 105 . 1997). the two most heterogeneous sites of religious denomination. which increases social interaction and social bonds between individuals with shared cultural values. this can be explained by the cultural diversity. The controls within the SUPREMISS study were more likely to report subjective religiosity than suicide attempters in four sites out of seven (Brazil. In particular. according to the results of the current study. family and cultural group levels (Wassenaar. In conclusion. 2004). these associations varied between dimensions of religiosity and across cultures. & Strock. Ellison. in India. the most pluralistic country. individual-level associations between different dimensions of religiosity and attempting suicide exist. Subsequently. The results from Vietnam can be attributed to its secularity. It is known from previous research that. subjective religiosity seems to be the crucial dimension of religiosity. as was also true for the effect of religious denomination. Ellison. While cultural diversity is seen as a national asset. the risk effect of subjective religiosity was an exceptional result again. the Islamic Republic of Iran and Sri Lanka). South Africa has been described as ‘‘The Rainbow Nation’’ because of its cultural diversity. subjective religiosity (considering him=herself to be a religious person) may serve as a protective factor against non-fatal suicidal behaviors in some cultures. even more specifically. Somewhat confusing results on organizational religiosity came from Estonia. the meaning of the fre- quency of church attendance within different cultures needs further explanation. is inversely associated with suicide rate (Ellison. Subjective religiosity is very informal and a deeply subjective psychological construct. No effect of organizational religiosity on suicide attempts was detected in Sri Lanka and South Africa. which may influence the overall way of thinking and mentality.

M. Sisask et al.

of religion on suicidal behaviors, therefore no specifically designed scales were included in the questionnaire. The information regarding religiosity 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 could be incomplete due to respondents’ memory bias and unwillingness to report honestly on sensitive issues like religiosity. 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, Ellison, & Strock, 2004). Another limitation is that religiosity has other aspects which 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. Moreover, religiosity is not the only factor which has an effect on attempted suicide. In the current study, the effect of the main socio-demographic variables (age, gender, marriage, employment, education) was statistically controlled and, even with other confounders, the indirect effects of religion are important. It can help to understand what factors influence health behaviors, social support and this knowledge can have valuable intellectual and practical implications, for example influencing public health (Flannelly, Ellison, & Strock, 2004).
AUTHOR NOTE

This paper is based on the data and experience obtained during the authors’ participation in the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS), a project funded by the World Health Organization and the participating field research centers. The collaborating investigators in this study have been (in alphabetical order): Dr. Damani De Silva, Colombo; Prof. Van

Tuong Nguyen, Hanoi; Prof. Lourens Schlebusch, Durban; Prof. Diego De Leo, Brisbane has acted as scientific advisor for the WHO SUPRE-MISS study. The Tallinn center obtained additional funding from the following agencies: the Estonian Health Insurance Fund; National Prevention of Suicide and Mental Ill-Health (NASP) at Karolinska Institute and Stockholm County Council’s Centre for Suicide Research and Prevention; the Estonian Scientific Foundation (Project No. 7132). Thanks are due to Maimu Nommik ˜ and Kathy McKay for their thorough linguistic and stylistic revision of the manuscript. Merike Sisask, Estonian-Swedish Mental Health and Suicidology Institute (ERSI) and Tallinn University, Tallinn, Estonia. Airi Varnik, Estonian-Swedish Mental ¨ Health and Suicidology Institute (ERSI) and Tallinn University, Tallinn, Estonia, and National Prevention of Suicide and Mental Ill-Health (NASP) at Karolinska Institute and Stockholm County Council’s Centre for Suicide Research and Prevention; WHO Lead Collaborating Centre of Mental Health Problems and Suicide Across Europe, Stockholm, Sweden. Kairi Kolves, Estonian-Swedish Men˜ tal Health and Suicidology Institute (ERSI), Tallinn, Estonia and Australian Institute for Suicide Research and Prevention (AISRAP), Brisbane, Australia. Jose M. Bertolote, Department of ´ Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland. The author is staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization. Jafar Bolhari, Tehran Psychiatric Institute (IUMS), Mental Health Research Center, Tehran, Islamic Republic of Iran.

Downloaded By: [Tartu University Library] At: 12:53 1 February 2010

ARCHIVES OF SUICIDE RESEARCH

53

106

Religiosity Against Attempted Suicide

Downloaded By: [Tartu University Library] At: 12:53 1 February 2010

Neury J. Botega, Department of Psychiatry, FCM – UNICAMP, Campinas, Brazil. Alexandra Fleischmann, Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland. The author is staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization. Lakshmi Vijayakumar, Department of Psychiatry, Voluntary Health Services & SNEHA, Chennai, India. Danuta Wasserman, National Prevention of Suicide and Mental Ill-Health (NASP) at Karolinska Institute and Stockholm County Council’s Centre for Suicide Research and Prevention; WHO Lead Collaborating Centre of Mental Health Problems and Suicide Across Europe, Stockholm, Sweden. Correspondence concerning this article should be addressed to Merike Sisask, Estonian-Swedish Mental Health and ˜ Suicidology Institute (ERSI), Oie 39, Tallinn 11615 Estonia. E-mail: merike. sisask@neti.ee
REFERENCES
Bertolote, J. M., & Fleischmann, A. (2002). A global perspective in the epidemiology of suicide. Suicidologi, 7(2), 6–7. Bertolote, J. M., Fleischmann, A., De Leo, D., et al. (2005). Suicide attempts, plans, and ideation in culturally diverse sites: The WHO SUPRE-MISS community survey. Psychological Medicine, 35(10), 1457–1465. Bolz, W. (2002). Psychological analysis of the Sri Lankan conflict culture with special reference to the high suicide rate. Crisis, 23(4), 167–170. Botega, N. J., de Azevedo Barros, M. B., de Oliveira, H. B., et al. (2005). Suicidal behavior in the community: Prevalence and factors associated with suicidal ideation. Revista Brasileira de Psiquiatria, 27(1), 45–53.

Breault, K. D. (1986). Suicide in America: A test of Durkheim’s theory of religious and family integration, 1933–1980. The American Journal of Sociology, 92(3), 628–656. Colucci, E., & Martin, G. (2008). Religion and spirituality along the suicidal path. Suicide & Life-Threatening Behavior, 38(2), 229–244. da Silva, V. F., de Oliveira, H. B., Botega, N. J., et al. (2006). Factors associated with suicidal ideation in the community: A case-control study. Cadernos de ´de ´blica, 22(9), 1835–1843. Sau Pu Dervic, K., Oquendo, M. A., Grunebaum, M. F., et al. (2004). Religious affiliation and suicide attempt. The American Journal of Psychiatry, 161(12), 2303–2308. Duberstein, P. R., Conwell, Y., Conner, K. R., et al. (2004). Poor social integration and suicide: Fact or artifact? A case-control study. Psychological Medicine, 34(7), 1331–1337. ´ Durkheim, E. (1897=2002). Suicide: A study in sociology. London and New York: Routledge Classics. Ellison, C. G., Burr, J. A., & McCall, P. L. (1997). Religious homogeneity and metropolitan suicide rates. Social Forces, 76(1), 273–299. Faria, N. M., Victora, C. G., Meneghel, S. N., et al. (2006). Suicide rates in the State of Rio Grande do Sul, Brazil: Association with socioeconomic, ´de cultural, and agricultural factors. Cadernos de Sau ´blica, 22(12), 2611–2621. Pu Flannelly, K. J., Ellison, C. G., & Strock, A. L. (2004). Methodologic issues in research on religion and health. The Southern Medical Journal, 97(12), 1231–1241. Fleischmann, A., Bertolote, J. M., De Leo, D., et al. (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. Hay, D. (2002). The spirituality of adults in Britain— recent research. Scottish Journal of Healthcare Chaplaincy, 5(1), 4–10. Kelleher, M. J., Chambers, D., Corcoran, P., et al (1998). Religious sanctions and rates of suicide worldwide. Crisis, 19(2), 78–86. Kerkhof, A. J. F. M., Bernasco, W., Bille-Brahe, U., et al. (1999). European parasuicide study interview schedule (EPSIS). In U. Bille-Brahe (Ed.), Facts and Figures: WHO=EURO. Copenhagen: WHO Regional Office for Europe. Khan, M. M., & Reza, H. (2000). The pattern of suicide in Pakistan. Crisis, 21(1), 31–35. Koenig, H. G. (2005). Faith and mental health: Religious resources for healing. West Conshohocken: Templeton Foundation Press.

54

VOLUME 14  NUMBER 1  2010

107

M. Sisask et al.

Downloaded By: [Tartu University Library] At: 12:53 1 February 2010

Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. New York: Oxford University Press. Lester, D. (2006). Suicide and Islam. Archives of Suicide Research, 10(1), 77–97. Moreira-Almeida, A., Neto, F. L., & Koenig, H. G. (2006). Religiousness and mental health: A review. Revista Brasileira de Psiquiatria, 28(3), 242–250. Musick, M. A., House, J. S., & Williams, D. R. (2004). Attendance at religious services and mortality in a national sample. Journal of Health and Social Behavior, 45(2), 198–213. Neeleman, J. (1998). Regional suicide rates in the Netherlands: Does religion still play a role? International Journal of Epidemiology, 27(3), 466–472. Neeleman, J., de Graaf, R., & Vollebergh, W. (2004). The suicidal process; prospective comparison between early and later stages. Journal of Affective Disorders, 82(1), 43–52. Nisbet, P. A., Duberstein, P. R., Conwell, Y., et al. (2000). The effect of participation in religious activities on suicide versus natural death in adults 50 and older. The Journal of Nervous and Mental Disease, 188(8), 543–546. Pescosolido, B. A., & Georgianna, S. (1989). Durkheim, suicide, and religion: Toward a network theory of suicide. American Sociological Review, 54(1), 33–48. Siegrist, M. (1996). Church attendance, denomination, and suicide ideology. The Journal of Social Psychology, 136(5), 559–566. Simpson, M. E., & Conklin, G. H. (1988). Socioeconomic development, suicide and religion: A test of Durkheim’s theory of religion and suicide. Social Forces, 67(4), 945–964.

Stack, S. (1983). The effect of religious commitment on suicide: A cross-national analysis. Journal of Health and Social Behavior, 24(4), 362–374. Stack, S. (2000). Suicide: A 15-year review of the sociological literature. Part II: Modernization and social integration perspectives. Suicide & Life-Threatening Behavior, 30(2), 163–176. Stack, S., & Kposowa, A. J. (2008). The association of suicide rates with individual-level suicide attitudes: A cross-national analysis. Social Science Quarterly, 89(1), 39–59. Stack, S., & Lester, D. (1991). The effect of religion on suicide ideation. Social Psychiatry and Psychiatric Epidemiology, 26(4), 168–170. Tousignant, M., Seshadri, S., & Raj, A. (1998). Gender and suicide in India: A multiperspective approach. Suicide & Life-Threatening Behavior, 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 prevention: 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.

ARCHIVES OF SUICIDE RESEARCH

55

108

APPENDIXES

.

CURRENT EPISODE HISTORY 6. SOCIO-DEMOGRAPHIC INFORMATION 5. HOPELESSNESS 12.Appendix 1 – SUPRE-MISS questionnaire for suicide attempters WHO/MSD/MBD/02. ALCOHOL AND DRUG RELATED QUESTIONS 9. TRAIT ANGER SCALE 13. IDENTIFICATION OF THE SITE 2. PRESENT SUICIDE ATTEMPT 4. SOCIAL SUPPORT 14. MENTAL HEALTH 8. PREVIOUS SUICIDE ATTEMPT HISTORY AND FAMILY DATA 7.1 Page 5 Annex 1 SUPRE-MISS QUESTIONNAIRE (SUPRE-MISS-Q) 1. PHYSICAL HEALTH. IDENTIFICATION OF THE PATIENT 3. BECK DEPRESSION INVENTORY 11. WHO WELL-BEING INDEX 10. WHO/DAS – PSYCHIATRIC DISABILITY ASSESSMENT SCHEDULE: SOCIAL ROLE PERFORMANCE (INTAKE) (INTAKE) (INTAKE) 111 . CONTACT WITH HEALTH SERVICES. LEGAL OR OFFENDING HISTORY / ANTISOCIAL BEHAVIOUR 15.

-15. Rate “888” if information is not available and “999” if item is not applicable.1 Page 6 SUPRE-MISS QUESTIONNAIRE INSTRUCTIONS FOR THE INTERVIEWER Please note that INTAKE part 1. 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.-3. have to be filled in alternatively by the interviewer in the presence of the interviewee and by the interviewee himself/herself. fill in numbers or write down the answer. or. have to be filled in by the interviewer and part 4. if requested.WHO/MSD/MBD/02. 112 .

3 Date of admission: 1. IDENTIFICATION OF THE SITE (INTAKE) 1.5 Attended by: Day / Month / Year: Hour / Minute: 1 _ Emergency Department 2 _ Intensive Care Unit 3 _ Other ward.3 Date of birth: 2. discharge date can be taken from the files) 1. since when: _ _ Day _ _ Month _ _ _ _ Year 2.2 Service/Hospital: 1.1 Page 8 SUPRE-MISS QUESTIONNAIRE (SUPRE-MISS-Q) 1.4 Present marital status: 1 _ Single 2 _ Married or living with permanent partner. since when: _ _ Day _ _ Month _ _ _ _ Year 3 _ Widowed.WHO/MSD/MBD/02. specify: __________ �� ___________ __/__/____ __/__ 1 2 3 1.2 Sex: 1 _ Male 2 _ Female 3 _ Transsexual Day / Month / Year: 1 2 3 ��� 888 999 __/__/____ 888 999 1 2 3 4 888 999 2.1 Country: 1.7 Date of discharge from hospital: Day / Month / Year: (in case of access to hospital administration files.8 Time of discharge from hospital: Hour / Minute: __/__/____ __/__ 2. IDENTIFICATION OF THE PATIENT (INTAKE) 2.6 Who accompanies the patient? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1.4 Time of admission: 1. since when: _ _ Day _ _ Month _ _ _ _ Year 4 _ Divorced / separated.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.1 Patient’s identification number: 2.5 Years of education: Years: �� 888 999 2. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 2 3 4 5 6 888 999 113 .

WHO/MSD/MBD/02. science. shop or market sales worker (e.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. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 2 3 4 5 6 7 8 9 10 11 888 999 2.g.g. senior official or manager Professional (e.1 Date of suicide attempt: Day / Month / Year: 3.) (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) Use the patient’s words: ______________________________ 2. art) Technician or associate professional (e. 1_ 2_ 3_ 4_ 5_ 6_ 7_ 8_ 9_ 10 _ 11 _ Full-time employed (including self-employed) Part-time employed (including self-employed) Employed.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. police officer) Skilled agricultural and fishery worker Craft and related trades worker (e.g.7 Does the patient currently go to school? 1 _ No 2 _ Yes 1 2 888 999 2.2 Day of the week: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3.g. waiter.1 Page 9 2.g.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_ 2_ 3_ 4_ 5_ 6_ 7_ 8_ 9_ 10 _ 11 _ Legislator.g. since when: _ _ Day _ _ Month _ _ _ _ Year Armed services Full-time student Disabled. but on sick leave Temporary work Unemployed. baker. PRESENT SUICIDE ATTEMPT (INTAKE) 3. health. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 2 3 4 5 6 7 8 9 10 11 888 999 3.3 Time: Hour / Minute: __/__/____ 888 999 __/__ 888 999 3. since when: _ _ Day _ _ Month _ _ _ _ Year Retired. medical assistant) Clerk (e. secretary) Service worker.4 Place: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 114 . since when: _ _ Day _ _ Month _ _ _ _ Year Housewife/homemaker Other. tailor) Plant or machine operator or assembler (e. driver) Elementary occupation (e. labourer) Armed forces Other. cleaner. permanently sick. painter. inspector.g.

1 Page 10 3. but no danger to life 2 _ medical attention/surgery required. 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. strangulation and suffocation X71 _ Intentional self-harm by drowning and submersion X72 _ Intentional self-harm by handgun discharge X73 _ Intentional self-harm by rifle. sedative-hypnotic. fire and flames X77 _ Intentional self-harm steam.6 Regarding the physical consequences and the danger to life for the attempted suicide: 0 _ no significant physical harm.WHO/MSD/MBD/02. 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.5 Method: _ _ _ _ _ _ _ _ _ _ _ (according to ICD-10 codes.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 0 1 2 3 888 999 0 1 2 888 999 60 65 70 75 80 61 66 71 76 81 62 63 64 67 68 69 72 73 74 77 78 79 82 83 84 888 999 115 . had/has danger to life 3. not elsewhere classified X62 _ Intentional self-poisoning by and exposure to narcotics and psychodysleptics (hallucinogens). 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. see below): X60 _ Intentional self-poisoning by and exposure to nonopioid analgesics. no medical treatment required 1 _ medical attention/surgery required. antipyretics and antirheumatics X61 _ Intentional self-poisoning by and exposure to antiepileptic. 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. antiparkinsonism and psychotropic drugs.

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 3.1 Page 11 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 2 888 999 116 .WHO/MSD/MBD/02.

usual situation). 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 10 888 999 117 . work or study.1 Page 12 INSTRUCTIONS FOR THE INTERVIEWER Please ask the interviewee the following questions and give the following introduction: “In the following.3. including children who are adopted? (Do not count children who were born dead.1 If yes. who are aged less than 16 years. 4. with whom did you live most of the time? (What was the usual situation?) (Household composition during past year.) (Number) 4. 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.8 During the past year.6 How many children do you have. specify: __________ 4. 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.7 With whom do you live presently (at the time you were admitted to the hospital)? (Household composition at time of suicide attempt). I will ask general questions about your age.4 How many times have you been divorced? (Number) 4. 4.1 Where were you born? (country) 4. living arrangements.3 Have you lived with different partners? 1 _No 2 _Yes. Your answers should reflect your actual 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. etc.5 How many children do or did you have. how many: _ _ 4. for whom you have shared or sole responsibility? (Number) 4.WHO/MSD/MBD/02. SOCIO-DEMOGRAPHIC INFORMATION 4.2 What is your nationality? 4.

how long in total have you been unemployed during the past year? (Fill in zero. driver) Elementary occupation (e. inspector. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Weeks 1 2 3 4 5 6 7 8 9 10 11 888 999 118 . 1_ 2_ 3_ 4_ 5_ 6_ 7_ 8_ 9_ 10 _ 11 _ Legislator. science.g.1 Page 13 4.g. have you been unemployed for some time? With unemployed I mean that you were looking for a job but could not find one.g. waiter.) Weeks: 4.10 Do you live in a rural or urban residence area? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) 1 _ Rural 2 _ Urban ������ 1 2 888 999 4. cleaner.9 Area of residence at time of the suicide attempt: (area or postal code) 4.WHO/MSD/MBD/02. senior official or manager Professional (e.g. If yes. painter. labourer) Armed forces Other.13a What is or was the occupation of your father? Use your own words: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. secretary) Service worker. art) Technician or associate professional (e. health.12 What was your annual income in the last year (after tax)? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. police officer) Skilled agricultural and fishery worker Craft and related trades worker (e. baker. if patient has not been unemployed. shop or market sales worker (e.11 During the past year (that is: between now and one year ago). tailor) Plant or machine operator or assembler (e.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. medical assistant) Clerk (e.g.g.g.

16 Why? What is your motive? (Use the patient’s words) _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _______________________________________________ 4. let us talk about the things that happened just before your admission to the hospital. CURRENT EPISODE HISTORY 5.WHO/MSD/MBD/02. 5.15 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 4.1 Was anybody near you when you tried to harm yourself? (e. in the same room.” Rate “888” if information is not available and “999” if item is not applicable.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. Please listen to all answers carefully and then give only one answer per question.) 0 _ Somebody present 1 _ Somebody nearby or in contact (e. telephone conversation.1 Page 14 4. telephone) 2 _ No one nearby or in contact 0 1 2 888 999 119 . Please indicate any question that is unclear to you.18 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 9 888 999 1 2 3 4 5 888 999 1 2 888 999 1 2 3 4 5 888 999 INSTRUCTIONS FOR THE INTERVIEWER Please ask the interviewee the following questions and give the following introduction: “After the general questions.g.g.17 Do you consider yourself to be a religious person? 1 _ No 2 _ Yes 4. Please think back to what happened. specify _ _ _ _ _ _ _ _ _ _ _ 4.

g. taking out insurance) 5. did you think about writing one? 0 _ Neither written a note. being alone in room with unlocked door) 2 _ Active precautions (e. giving gifts. say goodbye. such as avoiding others but doing nothing to prevent their intervention (e. that you had the intention to harm yourself? 0 _ None 1 _ Equivocal communication (ambiguous or implied) 2 _ Unequivocal communication (explicit) 5.g. being alone in room with locked door) 5.3 Did you do anything to prevent someone finding you? (e.7 Did you write one or more farewell letters? If yes.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 2 888 999 120 .5 Did you do anything.WHO/MSD/MBD/02.2 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. nor thought about writing one 1 _ Thought about writing one 2 _ Note written (present or torn up) 5.g.1 Page 15 5.) 0 _ No precautions at all 1 _ Passive precautions.6 Had you planned the attempt for some time? Did you make any preparations such as saving pills.4 Around the time you harmed yourself.8 Did you tell neighbours. etc. disconnect the telephone. such as paying bills. etc. 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.? 0 _ No preparation (no plan) 1 _ Minimal or moderate preparation 2 _ Extensive preparation (detailed plan) 5. 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. to whom? If no. put a note on the door. friends and/or family members. implicitly or explicitly. write a testament.

specify the person (=”model).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. __ 5.WHO/MSD/MBD/02. let us see if you have ever before deliberately poisoned or injured yourself. 6.10 Can you tell me what you hoped to accomplish by harming yourself? 0 _ Mainly to manipulate others 1 _ Temporary rest 2 _ Death 3 _ Other. __ 3. or if a family member has ever before done so. __ 2.5).5): Previous suicide attempt number: Please fill in the corresponding code: 1. 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. the method of the “model” event (see ICD-10 codes in 3.4 If no.1 Previous suicide attempt(s)? 1 _ No 2 _ Yes 6.13 In your opinion. specify: _ _ _ _ _ _ _ _ _ _ _ 5.1 If yes. PREVIOUS SUICIDE ATTEMPT HISTORY AND FAMILY DATA 6.12 Relation between alcohol/drug use (specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _) and current suicide attempt: 0 _ none/some previous ingestion. how many? (Number) 6.5. and the time lapse between “model” event and present suicide attempt. boy-/girlfriend) = “model”: 1 _ No 2 _ Yes 6. friend. 121 . __ __/__/____ 888 999 6.1 Page 16 5.2 When was the last one? Day / Month / Year: 1 2 888 999 888 999 �� 6. specify: _ _ _ _ _ _ _ _ _ _ _ 5.1.1. __ 4.2 If yes. what was the main reason why you harmed yourself? Why did you do this?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ______________________________________ 0 1 2 3 888 999 0 1 2 3 888 999 0 1 2 888 999 INSTRUCTIONS FOR INTERVIEWER Please ask the interviewee the following questions and give the following introduction: “In the following. method of previous suicide attempt (see ICD-10 codes in 3. skip sub-questions and go to question 6.3 Suicide of closest people (parents. 1 2 888 999 If yes.” Rate “888” if information is not available and “999” if item is not applicable.

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 6.2b “Model number 2: method (please fill in corresponding code. see 3.1 Page 17 6.5) _ _ _ _ _ _ 6.WHO/MSD/MBD/02.4.4. specify _ _ _ _ _ _ _ _ _ 6.1b “Model number 1: method (please fill in corresponding code.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 6.5) _ _ _ _ _ _ 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.5) _ _ _ _ _ _ 6. specify _ _ _ _ _ _ _ _ _ 6. see 3. specify _ _ _ _ _ _ _ _ _ 6.3a “Model” number 3: who? 1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ boy-/girlfriend 6 _ friend 7 _ other.3b “Model number 3: method (please fill in corresponding code.3c “Model” number 3: 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 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 6 888 999 122 . see 3.4.4.2a “Model” number 2: who? 1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ boy-/girlfriend 6 _ friend 7 _ other.4.4.4.

7 They ignored the attempt 1 _ No one 2 _ One person 3 _ Some people 1 _ No one 2 _ One person 3 _ Some people 1 _ No one 2 _ One person 3 _ Some people 1 _ No one 1 _ No one 1 _ No one 1 _ No one 2 _ One person 2 _ One person 2 _ One person 2 _ One person 3 _ Some people 3 _ Some people 3 _ Some people 3 _ Some people 1 2 3 1 2 3 1 2 3 1 1 1 1 2 2 2 2 3 3 3 3 888 999 888 999 888 999 888 999 888 999 888 999 888 999 123 . see 3. I will mention some possible reactions.WHO/MSD/MBD/02. your relatives and friends reacted to what you had done.4.5c “Model” number 5: 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 __ __ 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 6.4c “Model” number 4: 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 6.5.1 Page 18 6. tried to avoid you 6.5 They felt uncertain 6.5.5.2 6.5b “Model number 5: method (please fill in corresponding code.1 6. and I would like you to indicate whether such a reaction was shown by no one of your family and friends.5.6 They laughed at you 6.4.3 6.4. 6.5 I would like to know how then.5. by some of them. or by all of them.5a “Model” number 5: who? 1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ boy-/girlfriend 6 _ friend 7 _ other.4b “Model number 4: method (please fill in corresponding code. after the last time you poisoned/harmed yourself. specify _ _ _ _ _ _ _ _ _ 6.4a “Model” number 4: who? 1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ boy-/girlfriend 6 _ friend 7 _ other.5) _ _ _ _ _ _ 6.4.4.5) _ _ _ _ _ _ 6.5.4.4 They felt pity for you They showed understanding They showed anger or irritation They felt embarrassed. see 3. specify _ _ _ _ _ _ _ _ _ 6.5.

4 6.6.7.7.1.6 Did you feel afraid of yourself? 6.6.7.7 Have any of the following members of your biological family (i. 6.6.2 6.2.7 Did you feel uncertain of yourself? 6.1.7.1 6.1 6.6.10 Did you feel embarrassed? 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 6.6.7.7.7.6.2.5 Did you feel angry about yourself? 6.9 Did you feel uncertain towards others? 6.6 I would also like to know how you felt.2.6.2 6. after the previous time you poisoned/harmed yourself.7. Please think back to how you felt one week after the previous time you poisoned/harmed yourself. I will again mention some possible feelings.2.2 Did you feel released? 6.1 Page 19 6.4 Parent Brother or sister Child Grandparent Parent Brother or sister Child Grandparent Died by suicide: 1_No 1_No 1_No 1_No 2_Yes 2_Yes 2_Yes 2_Yes 1 1 1 1 2 2 2 2 888 999 888 999 888 999 888 999 Made a suicide attempt: 1_No 1_No 1_No 1_No 2_Yes 2_Yes 2_Yes 2_Yes 1 1 1 1 2 2 2 2 888 999 888 999 888 999 888 999 124 .6.8 Did you feel ashamed of yourself? 6.6.1.1 Did you feel good? 6.2.3 6. related by birth only) died by suicide or made a suicide attempt? 6.6.3 6. 6.1.4 Did you feel pity about yourself? 6.1. 6. and I would like you to say whether that applied to you.WHO/MSD/MBD/02.7.3 Proud because you managed to carry it through? 6.7.e.

14 Were you ever the witness of a disaster.8.17 Were you ever emotionally or psychologically tortured? 1_No 1_No 1_No 2_Yes 2_Yes 2_Yes INSTRUCTIONS FOR THE INTERVIEWER Please ask the interviewee the following questions and give the following introduction: “In the following.3.3.15 Were you ever a prisoner of war? 6.8.16 Were you ever physically tortured? 6.1 If yes.3 Do you have any longstanding physical illness or disability that has troubled you for at least one year? 1 _ No 2 _ Yes 7. MENTAL HEALTH 7.8.2 Weight in kg: 7.10 Were you ever emotionally abused? 1_No 1_No 2_Yes 2_Yes 1 1 1 1 1 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 6. sexually assaulted or raped? 1_No 2_Yes 6.WHO/MSD/MBD/02. accident or war which affected your ability to live as before? 1_No 2_Yes 6.12 Have you ever been physically or psychologically forced by anyone to engage in any unwanted sexual activity. CONTACT WITH HEALTH SERVICES.2 How long have you had this? 555 _ from birth on _ _ (Years) 555 _ _ 888 999 _ _ _ _ _ _ 888 999 _ _ _ _ _ _ 888 999 1 2 888 999 125 .4 A physical handicap or disability 1_No 2_Yes 6.1 Your race 1_No 2_Yes 6. I will ask general questions about your health. prejudice or hardship because of any of the following? 6.9 Were you ever threatened with abuse by someone? 6.3 Your political beliefs 1_No 2_Yes 6.” Rate “888” if information is not available and “999” if item is not applicable.5 Your sexual orientation 1_No 2_Yes 6.1 Height in cm: 7. PHYSICAL HEALTH.8.8. 7.2 Your religious beliefs 1_No 2_Yes 6. what is the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7. violence. Have you ever experienced any of the following events?” 6. accident or war which affected your ability to live as before? 1_No 2_Yes 6.1 Page 20 INSTRUCTIONS FOR THE INTERVIEWER Please ask the interviewee the following questions and give the following introduction: “Some people are affected by traumatic experiences in their lives.13 Were you ever the victim of a disaster.8 Have you ever suffered any persecution.11 Were you ever beaten so badly you had to see (or should have seen) a doctor? 1_No 2_Yes 6.

During these two weeks.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.5 Over the last three months. definitely” (3_).1 Date of last contact (before suicide attempt): 7. fair. good.WHO/MSD/MBD/02.1 If yes.1 Page 21 7. definitely 7.7.4 I would like you to think about the two weeks before you were admitted to the hospital. did you have thoughts about poisoning or injuring yourself? 1 _ No 2 _ To some extent 3 _ Yes. what was the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7.3 Medicines prescribed: 1 _ No 2 _ Yes.8 At the time of your last contact with the doctor.7. 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. 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.4 If medicines prescribed.2 Reason: 1 _ physical 2 _ psychological 3 _ both physical and psychological 7. 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 Day / Month / Year: 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 3 888 999 126 . or specialists during the last year? (excludes dentist. would you say your physical health on the whole has been excellent. what were your complaints? Did the doctor prescribe any medicines? 7.1 If “To some extent” (2_) or “Yes.8. ask: Did you use any of the medicines prescribed in that contact for self-poisoning (did you deliberately overdose)? 1 _ No 2 _ Yes 7. specify: __________ 7.4. psychiatrist) 1 _ not at all 2 _ one time 3 _ 2-3 times 4 _ 4 or more times 7.7.7.

5.11. Specify: _ _ _ _ _ _ _ _ _ _ 1 2 888 999 127 .5 7.2 7. etc. and for which reasons you were admitted? (Start with last admission.) Admission: Month/Year 1.3 7. if ever.11. 4. 7. codes should include treatment by private psychiatrist. day-care Community Mental Health Care Private psychologist or psychiatrist Consultation service for alcohol and drug related problems Consultation service for relational and sexual problems 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 1 1 1 1 1 1 2 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 7. telephone services. start facts on this treatment.) (EXAMPLE) 7. In-patient treatment after the present suicide attempt not included. 2. 6. have you been treated in a psychiatric hospital. in a psychiatric ward of a general hospital.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.) 1 _ Never 2 _ 1 time 3 _ 2-3 times 4 _ 4 times or more If “Never” (1_).11.4 7. as accurately as possible and for each admission separately describe: when you were admitted. continue with: Out-patient psychiatric treatment and day care. Do not code admissions after present suicide attempt.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.11. ? 1_No 2_Yes.10 If one or more times in-patient treatment: Could you.11. an example (based on health services in the Netherlands) is given below for reference.O.S. polyclinic service Psychiatric service. If patient was in in-patient psychiatric treatment at the time of the suicide attempt. ______ ______ ______ ______ ______ ______ Length of stay: Months ______ ______ ______ ______ ______ ______ Reason for admission: __________ __________ __________ __________ __________ __________ 1 2 3 4 888 999 Out-patient psychiatric treatment and day care 7.WHO/MSD/MBD/02.6 Psychiatric service.1 Page 22 In-patient psychiatric treatment (includes treatment on psychiatric ward of general hospital) 7.1 7. S.9 How many times. how long you stayed there.11. 3. 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”.

reproof.. During these two weeks. default of payment. depressive feelings. infidelity.16.1 If yes.16 Now I would like you to think about the two weeks before you were admitted to the hospital.15.7 Problems with police. 1 _ No 2 _ Yes 1 2 888 999 1 2 3 888 999 7. depressive feelings. e. recent provoked abortion: 1 _No 2 _1 month 3 _6 months 4 _1 year ago 7. what was the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7.2 With your family (father.5 Disability or serious physical illness: 1 _No 2 _1 month 3 _6 months 4 _1 year ago 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 7.15 Did you have any psycho-social difficulties during the last year with _ _ _ _ _ _ ? Specify how long ago: 7. by examples like: fears of places.15.8 Others: which? _ _ _ _ _ _ _ _ _ _ 1 _No 2 _1 month 3 _6 months 7.1 With your partner (fights. obsessions or compulsions.g. others): 1 _No 2 _1 month 3 _6 months 4 _1 year ago 7. to be compelled to clean yourself or your house.15. 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. etc.WHO/MSD/MBD/02. death): 1 _No 2 _1 month 3 _6 months 4 _1 year ago 7. other emotions or thoughts that influenced you repeatedly like obsessions.1 If yes. justice: 1 _No 2 _1 month 3 _6 months 4 _1 year ago 4 _1 year ago 7.14.3 Work/studies (dissatisfaction. etc. conflicts): 1 _No 2 _1 month 3 _6 months 4 _1 year ago 7.15. excessive fear of people in general. if needed.13 This question only.1 Page 23 7.2 How long have you had this? 555 _ from birth on _ _ (Years) 555 _ _ 888 999 7.14. separation.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.15.6 Pregnancy (unwanted?).15.15.15. mother.4 Serious financial problems (housing.) 1 _ No 2 _ Yes 1 2 888 999 7. anxiety to leave your house. siblings. hunger.). 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. what was the matter with you? _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ 128 .): 1 _No 2 _1 month 3 _6 months 4 _1 year ago 7. unemployment. alcohol. or any other psychological condition)? (Please note that it concerns afflictions which must severely hinder normal functioning.

22 Do you receive psychological/psychiatric treatment currently? 1 _ No 2 _ Yes 1 2 888 999 129 .18.3 Five years from now 1 2 3 3 3 4 4 4 5 5 5 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 7.4 Five years ago 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 888 999 888 999 888 999 888 999 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 7.17.20 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 1 2 3 4 5 888 999 1 2 888 999 7.17.2 One year from now 1 2 7.18 How satisfied with your life do you think you will be? (from “1” = dissatisfied to “5” = satisfied) 7.21.21 Did you take any psychopharmacologic drugs during the last month? 1 _ No 2 _ Yes 7.1 If yes.1 Page 24 7.17 How satisfied are you with your life? (from “1” = dissatisfied to “5” = satisfied) 7. with whom? 1 _ parent 2 _ child 3 _ sister or brother 4 _ spouse 5 _ other relative.WHO/MSD/MBD/02. specify _ _ _ _ _ _ _ _ _ _ 7.1 If yes.1 If yes.1 30 Days from now 1 2 7. which one(s)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 2 1 2 3 4 5 6 888 999 888 999 7.17. specify _ _ _ _ _ _ _ _ _ _ 7.20.2 30 days ago 7. with whom? 1 _ boy-/girlfriend 2 _ friend 3 _ colleague 4 _ neighbour 5 _ health professional 6 _ other.19.18.18.3 One year ago 7.17.1 Now 7.

) 1. if DSM-IV.23.25 Psychiatric diagnosis made by (name of the person): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7.26 Date of psychiatric diagnosis: 7.2 Distrustful.23.7 Incongruent.23.23 Psychological exam “0” = absent “1” = light “2” = moderate “3” = marked “4” = severe 7.4 Depressive mood 7. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. uneasy 7.1 Page 25 7.11 Diminished intelligence 7.5 Anxious.13 Suicidal ideation 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 0 1 2 3 4 888 999 0 1 2 3 4 888 999 7.23.30 Type of prescribed medicines: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 130 .24 Psychiatric diagnosis.23.23.8 Delirium. tense. according to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (preferably ICD-10.10 Hallucinations 7. excited mood 7.6 Euphoria.WHO/MSD/MBD/02.23.27 Time of psychiatric diagnosis: Day / Month / Year: Hour / Minute: __/__/____ 888 999 __/__ 888 999 7.1 Psycho-motor slowdown 7.23. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7.28 Former psychiatric diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7.23.3 Histrionic 7. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4.9 Thought disturbance 7.23. misinterpretations 7. only axis I diagnosis required.29 Somatic diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7.23. flattened emotions 7.12 Excessive preoccupation with physical functions 7. defensive 7.23.23.

liquor.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8. Dilaudid.2. which of the following substances have you ever used? 8. specify _ _ _ _ _ _ _ _ _ _ 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 1 1 1 1 1 1 2 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 1 _ No 2 _ Yes 1 _ No 2 _ Yes 1 _ No 2 _ Yes 1 _ No 2 _ Yes 1 2 1 2 1 2 1 2 Probe if all answers are negative and ask: Not even when you were in school? 8. Seconal.) 8.2. etc. mushrooms. spray paint.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8. PDP. etc. 8. ecstasy.2. how often have you used the substances you mentioned? 8.1 Page 26 INSTRUCTIONS FOR THE INTERVIEWER 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. etc.2 If yes to any of these items. Dilaudid.1 Tobacco products (cigarettes.2 Alcoholic beverages (beer.) Marijuana (pot. PDP. diet pills. spray paint.1. etc.1.5 Stimulants or Amphetamines (speed. cigars.4 8.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8. Percodan. grass. Quaaludes. acid.6 Inhalants (nitrous.1.1 8. specify _ _ _ _ _ _ _ _ _ _ 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 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 5 888 999 131 .9 Heroin. grass. liquor. etc. chewing tobacco. Librium. etc.1.3 Marijuana (pot.8 Hallucinogens (LSD. Librium.6 8. hash.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8. etc. gasoline.1. etc. Seconal. chewing tobacco.2. Demoral.2 8.2.1.2.1. etc.9 Heroin. etc.10 Other. wine. acid.2. Haldol.3 8. etc.7 Sedatives or Sleeping Pills (Valium. Darvon.” Rate “888” if information is not available and “999” if item is not applicable. etc.2. Haldol. Methadone or Pain Medication (codeine. Xanax.5 8. Morphine.1. ecstasy. Xanax. gasoline. Fiorional.2. Darvon. diet pills.2. glue.) Alcoholic beverages (beer.) 8. Special K.1. Fiorional. Special K. Methadone or Pain Medication (codeine.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8.WHO/MSD/MBD/02. etc. Percodan. paint thinner)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8. Morphine.4 Cocaine or Crack? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 8.1 In your life. ALCOHOL AND DRUG RELATED QUESTIONS 8. cigars. wine. mushrooms. Quaaludes. paint thinner) Sedatives or Sleeping Pills (Valium.) Cocaine or Crack Stimulants or Amphetamines (speed. in the past three months. Demoral.8 Hallucinogens (LSD.) Inhalants (nitrous.7 Tobacco products (cigarettes. hash.1. glue.) 8. etc.10 Other.

79g): Example: 330ml beer x 0.5 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. wine 12% and spirits 40%. bottle. Usually a regular beer contains 4-5% alcohol.3 When was the last time you had a drink containing alcohol? 1 _hour ago 2 _days ago 3 _months ago 1 2 3 888 999 8.4.4 How many standard drinks* did you have on that occasion? _ _ number of drinks 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 __ __ __ __ __ 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 11 888 999 132 . 40 ml of whisky/liquor.3 How many standard drinks* of spirits did you have on that occasion? _ _ number of drinks 8.1 How many standard drinks* of beer did you have on that occasion? _ _ number of drinks 8. all types of beverages together) 8.2 How many standard drinks* of wine did you have on that occasion? _ _ number of drinks 8.4 How many standard drinks* of other (please specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) did you have on that occasion? _ _ number of drinks * 330 ml of regular beer (can.) 8. 120 ml of wine. glass).6 On those days when you drank. how many drinks did you usually have? _ _ drinks (Record exact number of drinks.79 = approximately 10g pure alcohol.4.04 x 0.4.4.1 Page 27 8. TO BE ADAPTED TO LOCAL CODING CATEGORIES (One standard drink contains 10g of pure alcohol.WHO/MSD/MBD/02. The ethanol content is calculated as: Amount in ml x percentage of alcohol in the beverage x ethanol conversion factor (1ml ethanol=0.

Please stay with the interviewee all along and offer to clarify any questions that may arise.WHO/MSD/MBD/02.1 Page 28 INSTRUCTIONS FOR THE INTERVIEWER At this time. 133 . Please take back the questionnaire for the parts 14. and enter the answers. The chosen answer has to be marked with an “X”.-13. please hand the questionnaire to the interviewee for the parts 9. and 15. Rate “888” if information is not available and “999” if item is not applicable.

please start filling in the questionnaire.1 Page 29 INSTRUCTIONS FOR THE INTERVIEWEE In the following. 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. Notice that higher numbers mean better well-being.WHO/MSD/MBD/02. if requested. Please mark the chosen answer directly after the corresponding question. you will find questions regarding various aspects of your life. Try not to stay with one question too long. fill in numbers or write down the answer. for example “3 X” or “X Yes”.. please do not hesitate to ask the interviewer. Mark “888” if information is not available and “999” if item is not applicable. e.” “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. 9. In case you have any questions or in case anything is unclear to you. If you do not have any questions at this time.1 I have felt cheerful and in good spirits 9. your wellbeing or social issues.4 I have felt fresh and rested 9.5 My daily life has been filled with things that interest me 5_ 5_ 5_ 5_ 5_ 4_ 4_ 4_ 4_ 4_ 3_ 3_ 3_ 3_ 3_ 2_ 2_ 2_ 2_ 2_ 1_ 1_ 1_ 1_ 1_ 0_ 0_ 0_ 0_ 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 5 888 999 134 . Please read both the questions and the answers you can choose from carefully and answer what comes to your mind first. Only make one indication per statement.2 I have felt calm and relaxed 9.3 I have felt active and vigorous 9.g. PLEASE GIVE ONLY ONE ANSWER PER QUESTION! Please mark the chosen answer with an “X”. or.

2 _ I am disgusted with myself. 2 _ I don’t get real satisfaction out of anything anymore.5 0 _ I don’t feel particularly guilty. but I would not carry them out. 10. 3 _ I am so sad or unhappy that I can’t stand it. 1 _ I feel discouraged about the future. 2 _ I feel I have nothing to look forward to. 3 _ I feel guilty all of the time. 1 _ I don’t enjoy things the way I used to. 10. 2 _ I would like to kill myself. 10.6 0 _ I don’t feel I am being punished. 10.7 0 _ I don’t feel disappointed in myself. Be sure to read all statements in each group before making your choice.9 0 _ I don’t have any thoughts of killing myself. 3 _ I feel I am a complete failure as a person. 2 _ I blame myself all the time for my faults.8 0 _ I don’t feel I am any worse than any body else.3 0 _ I do not feel like a failure. 1 _ I am critical of myself for my weaknesses or mistakes. Then pick out the one statement in each group which best represents the way you feel right now. 1 _ I feel I have failed more than the average person. 1 _ I feel I may be punished.1 Page 30 10. 2 _ I expect to be punished. 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 3 888 999 135 . 3 _ I hate myself. 3 _ I feel that the future is hopeless and that things cannot improve. 1 _ I have thoughts of killing myself. 3 _ I would kill myself if I had the chance. 10. 10. 2 _ I feel quite guilty most of the time.” 10. 1 _ I feel sad. 2 _ I am sad all the time and I can’t snap out of it. BECK DEPRESSION INVENTORY Instruction: “Below you will find groups of statements. 2 _ As I look back on my life. 10. 1 _ I am disappointed in myself.2 0 _ I am not particularly discouraged about the future.1 0 _ I do not feel sad. 3 _ I am dissatisfied or bored with everything. 10. 3 _ I blame myself for everything bad that happens. Please read each group of statements carefully. 1 _ I feel guilty a good part of the time.4 0 _ I get as much satisfaction out of things as I used to. all I can see is a lot of failures. 3 _ I feel I am being punished.WHO/MSD/MBD/02.

18 0 _ My appetite is no worse than usual. 2 _ I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. but now I can’t cry even though I want to.15 0 _ I can work as well as before. 3 _ I believe I look ugly.17 0 _ I don’t get more tired than usual. 1 _ My appetite is not as good as it used to be. 2 _ I have to push myself very hard to do anything. 10. 10. 2 _ I get tired from doing almost anything. 3 _ I can’t make decisions at all anymore. 1 _ It takes an extra effort to get started at doing something. 10.16 0 _ I can sleep as well as usual. 10.19 0 _ I haven’t lost much weight.13 0 _ I make decisions about as well as I ever did. 2 _ I cry all the time now. 1 _ I am less interested in other people than I used to be.1 Page 31 10. 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 3 888 999 136 . 2 _ I have greater difficulty in making decisions than before. if any lately. 10.WHO/MSD/MBD/02. 2 _ I have lost more than 10 pounds. 1 _ I don’t sleep as well as I used to. 3 _ I used to be able to cry. 1 _ I cry more now than I used to. 3 _ I am too tired to do anything.10 0 _ I don’t cry any more than usual. 2 _ I feel irritated all the time now. 1 _ I get annoyed or irritated more easily than I used to. 10.12 0 _ I have not lost interest in other people. 2 _ I feel that there are permanent changes in my appearance that make me look unattractive. 1 _ I get tired more easily than I used to. 3 _ I wake up several hours earlier than I used to and cannot get back to sleep. 3 _ I have no appetite at all anymore. 2 _ My appetite is much worse now. 3 _ I have lost all of my interest in other people. 1 _ I have lost more than 5 pounds. 10. 10. 1 _ I put off making decisions more than I used to.11 0 _ I am no more irritated now than I ever am. 3 _ I have lost more than 15 pounds. 3 _ I can’t do any work at all. 3 _ I don’t get irritated at all by the things that used to irritate me. 1 _ I am worried that I am looking old or unattractive.14 0 _ I don’t feel I look any worse than I used to. 2 _ I have lost most of my interest in other people. 10.

12. 2 _ I am very worried about physical problems and it’s hard to think of much else. 10. 12. 12.3 I am a hot headed person. that I cannot think about anything else. 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 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 12. 0 1 888 999 0 1 2 3 888 999 0 1 2 3 888 999 11.1 I have a fiery temper. 3 _ I have lost interest in sex completely. 2 _ I am much less interested in sex now. I say nasty things. HOPELESSNESS Instruction: “Below. “1” = Almost never “2” = Sometimes “3” = Often “4” = Almost always 12. 1 _ False 2 _ True 1 2 888 999 12. 1 _ I am less interested in sex than I used to be.6 I feel infuriated when I do a good job and get poor evaluation.1 Page 32 10. 0 _ No 1 _ Yes 10. 12.4 It makes me furious when I am always criticized in front of others. 12.7 I fly off the handle. or constipation. 3 _ I am so worried about physical problems. I feel like hitting someone.2 I am quick-tempered.” 11.10 When I get frustrated.9 When I get mad. 12. 1 137 . TRAIT ANGER SCALE Instruction: “The following questions deal with feelings of anger.WHO/MSD/MBD/02. 1 _ I am worried about physical problems such as aches and pains.1 My future seems dark to me.22 0 _ I have not noticed any recent change in my interest in sex. or upset stomach. Please indicate for each statement whether it applies to you in general (how you generally feel). there is one statement regarding your future. Please mark the option which reflects best the way you feel at the present time. Mark only one answer that represents best how you generally feel.5 I get angry when I’m slowed down by others’ mistakes.8 I feel annoyed when I am not given recognition for doing good work.20 I am purposely trying to lose weight by eating less.21 0 _ I am no more worried about my health than usual. 12. 12.

8.2 Friends: 0 13.2.2 Friends: 0 1 2 13.3.2 Friends: 0 0 0 0 1 1 1 1 2 2 2 2 0 1 2 0 1 2 0 1 2 0 1 2 888 999 888 999 888 999 888 999 WHETHER YOU GET SUPPORT FROM 13.7 Do you feel that you give the practical support that is needed from you? 13. etc. It includes that people are available to share worries with.1 Family: 13. looking after you or doing the shopping when you are ill. etc.1 Family: 0 1 2 13.Practical support refers to support concerning daily activities such as looking after your house when you are away.2 Friends: 0 WHETHER YOU ARE NEEDED FOR SUPPORT BY 13. It also includes financial support.1 Family: 0 13.3 Do you feel that you get the practical support you need? 13.6.2 Friends: 0 13.8.1 Page 33 13.6.1 Family: 0 1 2 13. .1 Do you feel that you need practical support? 13.8.4.1. 138 . SOCIAL SUPPORT Instruction: “The following part deals with the question of giving and getting support from or to family and friends. looking after your children.2 Friends: 13. “0” = No.4.8 Do you feel that you give the moral support that is needed from you? 13.6 Do you feel that you are needed for moral support? 13.2 Friends: 0 1 1 1 1 2 2 2 2 0 1 2 0 1 2 0 1 2 0 1 2 888 999 888 999 888 999 888 999 1 1 1 1 2 2 2 2 0 1 2 0 1 2 0 1 2 0 1 2 888 999 888 999 888 999 888 999 WHETHER YOU GIVE SUPPORT TO 13.1 Family: 0 13.1 Family: 0 13. Two kinds of support are distinguished: . to talk about personal problems.5 Do you feel that you are needed for practical support? 13.4 Do you feel that you get the moral support you need? 13.5.2.2 Do you feel that you need moral support from? 13.2 Friends: 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 888 999 888 999 888 999 888 999 Instruction: Please hand the questionnaire back to the interviewer at this point.WHO/MSD/MBD/02.5.1 Family: 13. 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.1 Family: 0 13.3. pets or flowers. very much WHETHER YOU NEED SUPPORT FROM 13.8. not at all “1” = To some extent “2” = Yes.Moral support refers to emotional support when minor or major problems arise. Please read each question carefully.1.

1.1 Page 34 INSTRUCTIONS FOR THE INTERVIEWER Please take the questionnaire back from the interviewee.9.1 14. specify: 1 _ once 2 _ 2-3 times 3 _ several times Day / Month / Year: 1 2 1 2 3 888 999 888 999 14.2 14. what was the major reason for the most recent conviction? 14. what was the major reason for the most recent imprisonment? 14.4 14.3 If yes.4 14.5 14.1.1.5.6 Property offences Violent offences Political or administrative crimes Substance use Sexual offences Other: (specify) _ _ _ _ _ _ _ _ _ 1 _No 1 _No 1 _No 1 _No 1 _No 1 _No 2 _Yes 2 _Yes 2 _Yes 2 _Yes 2 _Yes 2 _Yes 1 1 1 1 1 1 __/__/____ 888 999 2 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 14.1 14.9.9.6 Property offences Violent offences Political or administrative crimes Substance use Sexual offences Other: (specify) _ _ _ _ _ _ _ _ _ 1 _No 1 _No 1 _No 1 _No 1 _No 1 _No 2 _Yes 2 _Yes 2 _Yes 2 _Yes 2 _Yes 2 _Yes 1 1 1 1 1 1 __/__/____ 888 999 2 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 139 .5 14.5.5.2 14. Please ask the interviewee the following questions and give the following introduction: “I would like to continue with some questions on legal matters.5. specify: 1 _ once 2 _ 2-3 times 3 _ several times Day / Month / Year: 1 2 1 2 3 888 999 888 999 14.1 Have you done any of the following during the past five years? 14.2 14.5.9.2 Have you ever been convicted of a criminal offence (excluding traffic offences)? 1 _ No 2 _ Yes 14.9.3 14.WHO/MSD/MBD/02.4 If yes.1 14.5.” Rate “888” if information is not available and “999” if item is not applicable.1.7 If yes. LEGAL OR OFFENDING HISTORY / ANTISOCIAL BEHAVIOUR 14.3 14. specify the date of the most recent conviction: 14.3 14.5 14.9. specify the date of the most recent imprisonment: 14.8 If yes.6 Have you ever been to prison (for other than traffic reasons)? 1 _ No 2 _ Yes 14.4 14.1.5 If yes.6 boycott occupation of buildings and sit-ins blocking traffic personal violence damage to property violent demonstration 1 _No 1 _No 1 _No 1 _No 1 _No 1 _No 2 _Yes 2 _Yes 2 _Yes 2 _Yes 2 _Yes 2 _Yes 1 1 1 1 1 1 2 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 14.1. 14.9 If yes.

taking interest in his/her problems.” Rate “888” if information is not available and “999” if item is not applicable. Ask for examples. money.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. putting to bed. (ii) patient’s participation in decision-making concerning the household. such as having meals together. 15. …) listed for each question and then indicate the rating for each question. ii. etc.). decisions about the children. 15. looking after child’s needs – for older children).1 Page 35 INSTRUCTIONS FOR THE INTERVIEWER In the following part. etc. going out or visiting together.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. (ii) interest in child (e. doing domestic chores.g. Make a rating without regard to whether patient is asked to participate.g. e. playing games. etc.. consider and rate only (ii). left on his/her own or rejected in some way. 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. 15. For housewives. please inquire about the issues (i.WHO/MSD/MBD/02.) (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. news. feeding. watching television. talking to spouse about ordinary events. 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 5 888 999 140 . the children. consider the household jobs that a housewife usually has to do.1 Participation in household activities during past month Inquire about: (i) patient’s participation in common activities of the household. reading to. taking to school – for small children. If children are not living with patient.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.g. etc. playing. Please give the following introduction: “I would like to finish with some questions regarding your everyday life. school work.g.

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 steps undertaken to get a job or start studies. If the patient is a housewife.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. colleagues. other students etc.. (ii) sickness. use judgement about local expectations concerning housewife’s seeking employment outside the home. and level of intelligence. make a rating after consulting alternative sources. (ii) efforts to obtain such information..) 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 5 888 999 141 . (ii) with neighbours. 15.g. Household work is excluded (rate in question 1. if patient is working.g. normally requiring action (e.WHO/MSD/MBD/02. For patients living in hostels or other communal accommodation. accident or incident involving other people. 15. (iii) minor emergencies (e.). e. If key informant is unable to provide information. customers. 15. patient left to baby-sit.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. administrators.. breakdown of equipment). (ii) actual relationship or contacts sought by patient (regardless) of whether sexual relations involved or not). students are included. education.. observing the rules. etc. if patient is a housewife or not working. include frictions arising with other boarders. such as: (i) sickness or accident affecting a family member. as commensurate with his/her social background. other people in the community etc. 15. anger or marked irritability arising in social situations outside own home. 15.) Consider: (i) interest in obtaining or returning to a job or studies. (i) with supervisors. (iii) with teachers. (ii) quality of performance and output. annoyance. etc.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. etc.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.1 Page 36 15. (iv) any other situation out of the routine for the patient. requested to pass on a message. if patient is a student.g.9 Interests and information during the past month Consider: (i) interest shown by patient in local or world events or in other matters.

family data. if item is not applicable. mental health.Appendix 2 – SUPRE-MISS community survey questionnaire WHO/MSD/MBD/02. 142 .1 Page 37 Annex 2 SUPRE-MISS COMMUNITY SURVEY INSTRUCTIONS FOR THE INTERVIEWER The questionnaire comprises questions regarding socio-demographic information. physical 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. the history of suicide attempt. contact with health services. Mark “888” if information is not available and “999”. the country and the site in the questionnaire at the beginning (see 0.3 on the first page).1 to 0. Please enter the subject’s identification number.

your family. please do not hesitate to ask the interviewer.9 How many children do you have. for example “X Yes” or “3 X”. including children who are adopted? (Do not count children who were born dead. for whom you have shared or sole responsibility? (Number) _ _ �� �� �� 143 . fill in numbers or write down the answer.3 Where were you born? (country) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1.5 Present marital status: 1 _ Single 2 _ Married or living with permanent partner. Please read the questions carefully and answer what comes to your mind first. how many: _ _ __/__/____ 888 999 1 2 3 4 888 999 1 2 888 999 888 999 888 999 888 999 1.7 How many times have you been divorced? (Number) _ _ 1. since when: _ _ Day _ _ Month _ _ _ _ Year 3 _ Widowed. since when: _ _ Day _ _ Month _ _ _ _ Year 4 _ Divorced / separated. 1.3 Site: __ __________ __________ INSTRUCTIONS FOR THE INTERVIEWEE In the following. and your physical and mental health.6 Have you lived with different partners? 1 _ No 2 _ Yes. you will find questions regarding yourself. Try not to stay with one question too long.1 Sex: 1 _ Male 2 _ Female 3 _ Transsexual 1 2 3 888 999 1. the community you live in.2 Country: 0. In case you have any questions or in case anything is unclear to you.2 Date of birth: _ _ Day _ _ Month _ _ _ _ Year 1.4 What is your nationality? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1. since when _ _ Day _ _ Month _ _ _ _ Year 1. PLEASE GIVE ONLY ONE ANSWER PER QUESTION! Please mark an “X” on the “_” next to the answer you choose.) (Number) _ _ 1. if requested. 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 Identification number: 0.1 Page 38 SUPRE-MISS COMMUNITY SURVEY 0. or. Mark “888” if information is not available and “999” if item is not applicable. SOCIO-DEMOGRAPHIC INFORMATION 1.8 How many children do or did you have. Please mark the chosen answer directly after the corresponding question.WHO/MSD/MBD/02. who are aged less than 16 years.

g.g. specify: _ _ _ _ _ _ _ _ _ _ _ 1. painter. police officer) Skilled agricultural and fishery worker Craft and related trades worker (e. art) Technician or associate professional (e. shop or market sales worker (e. inspector. 1_ 2_ 3_ 4_ 5_ 6_ 7_ 8_ 9_ 10 _ 11 _ Legislator. baker. labourer) Armed forces Other. cleaner.g.g.14b Which of the following occupational categories best describes your occupation? Choose only one answer according to your most important occupation.g. science. tailor) Plant or machine operator or assembler (e.g. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 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 11 888 999 144 .12 Years of education: _ _ Years 1. medical assistant) Clerk (e. secretary) Service worker.1 Page 39 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. senior official or manager Professional (e.) (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) Use your own words: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 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. health.WHO/MSD/MBD/02. waiter.11 Do you live in a rural or urban residence area? (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) 1 _ Rural 2 _ Urban 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. driver) Elementary occupation (e.g.

permanently sick. specify _ _ _ _ _ _ _ _ _ _ _ _ _ 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. If yes.21 Do you consider yourself being a religious person? 1. since when: _ _ Day _ _ Month _ _ _ _ Year Armed services Full-time student Disabled. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 2 3 4 5 6 7 8 9 10 11 888 999 1. since when: _ _ Day _ _ Month _ _ _ _ Year Housewife/homemaker Other.WHO/MSD/MBD/02. if you have not been unemployed.1 Page 40 1. 1_ 2_ 3_ 4_ 5_ 6_ 7_ 8_ 9_ 10 _ 11 _ Full-time employed (including self-employed) Part-time employed (including self-employed) Employed.20 Why? What is your motive? (Use your own words) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1. but on sick leave Temporary work Unemployed.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.17 What was your annual income in the last year (after tax)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ (TO BE ADAPTED TO LOCAL CODING CATEGORIES!) 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 1.16 During the past year (that is: between now and one year ago). since when: _ _ Day _ _ Month _ _ _ _ Year Retired.) (Weeks) _ _ Weeks 1. how long in total have you been unemployed during the past year? (Fill in zero. have you been unemployed for some time? With unemployed I mean that you were looking for a job but could not find one.22 What is your preferred sexual orientation? 1 _ Heterosexual 2 _ Homosexual 3 _ Bisexual 4 _ Uncertain 5 _ Refused to answer 1 _ No 2 _ Yes __ 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 5 888 999 145 .

2.6 What was the method of this first suicide attempt (How did you try to kill yourself)? _______________ 2.3.2 Did this happen to you at all in the last twelve months? 2.1 Have you ever seriously thought about committing suicide? 1_ No 2_ Yes If answer is no.3.5 Thinking about the first time you ever attempted suicide.4 Did you make a suicide attempt at all in the last twelve months? _ _ years old _ _ years old 1_ No 2_ Yes �� �� �� 1 2 888 999 888 999 888 999 888 999 2. 3 _ My attempt was a cry for help.3 How old were you the last time this happened to you? 2.1 How old were you the first time this happened? 2.WHO/MSD/MBD/02.3.1.8 Did this first suicide attempt require medical attention? 1_No 2_Yes 3_Don’t know 2. SUICIDE ATTEMPT HISTORY AND FAMILY DATA 2.3.3 How old were you the last time this happened to you? 2. 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. skip sub-questions and go to question 2.3. 4 _ Don’t know. skip sub-questions and go to question 2.1 Page 41 2. 2 _ I tried to kill myself but knew that the method was not fool-proof.2. I did not intend to die.3 How old were you the last time this happened to you? 2.1. 2.7 Did this first suicide attempt result in an injury or poisoning? 1_No 2_Yes 3_Don’t know 2.2 Did this happen to you at all in the last twelve months? 2.1.2.3.3.3 Have you ever attempted suicide? _ _ years old 1_ No 2_ Yes _ _ years old 1_ No 2_ Yes �� 1 2 888 999 888 999 888 999 888 999 �� 1 2 If answer is no.3.2 Have you ever made a plan for committing suicide? _ _ years old 1_ No 2_ Yes _ _ years old 1_ No 2_ Yes 1 2 888 999 �� 1 2 888 999 888 999 888 999 888 999 �� 1 2 If answer is no. 2.3.1 How many times ever in your lifetime have you attempted suicide? (Number of times) _ _ 2. 2.9 Did this first suicide attempt require hospital admission for one night or longer? 1_No 2_Yes 3_Don’t know 1 2 3 4 888 999 1 2 3 1 2 3 1 2 3 888 999 888 999 888 999 146 .2.4.2.1 How old were you the first time this happened? 2. skip sub-questions and go to question 2.2 How old were you the first time this happened? 2.3.

3.14 Did this last suicide attempt require hospital admission for one night or longer? 1_No 2_Yes 3_Don’t know 2. I did not intend to die.2 Made a suicide attempt: 2.3 2.4.2.1.4.2 2.4 Family history of suicidal behaviour: Have any of the following members of your biological family (i.4. 3 _ My attempt was a cry for help.3.4. 2 _ I tried to kill myself but knew that the method was not fool-proof.2 2.1.1.4 Parent Brother or sister Child Grandparent 1_No 1_No 1_No 1_No 2_Yes 2_Yes 2_Yes 2_Yes 1 2 3 4 888 999 1 2 3 1 2 3 1 2 3 888 999 888 999 888 999 1 1 1 1 2 2 2 2 888 999 888 999 888 999 888 999 2.1 2.4. 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.1.e.4.13 Did this last suicide attempt require medical attention? 1_No 2_Yes 3_Don’t know 2. 4 _ Don’t know. related by birth only) died by suicide or made a suicide attempt? 2.4.4.3.4.WHO/MSD/MBD/02.2.1 Page 42 2.2.2. 2.12 Did this last suicide attempt result in an injury or poisoning? 1_No 2_Yes 3_Don’t know 2.4.10 Thinking about the last (most recent) time you attempted suicide.3.3 2.4 Parent Brother or sister Child Grandparent 1_No 1_No 1_No 1_No 2_Yes 2_Yes 2_Yes 2_Yes 1 1 1 1 2 2 2 2 888 999 888 999 888 999 888 999 147 .1 Died by suicide: 2.1 2.3.11 What was the method of this last suicide attempt (How did you try to kill yourself)? _______________ 2.

2 Weight in kg _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3.WHO/MSD/MBD/02.3. if ever.6).1 Page 43 3.2 How long have you had this? 555 _ from birth on _ _ (Years) 555 _ _ 888 999 _____ _____ 1 2 888 999 888 999 888 999 In-patient psychiatric treatment (includes treatment on psychiatric ward of general hospital) 3. continue with: Out-patient psychiatric treatment and day care (3.4 How many times.3 Do you have any longstanding physical illness or disability that has troubled you for at least one year? 1 _ No 2 _ Yes 3. PHYSICAL HEALTH. meaning: “you were in the hospital both night and day”).1 Height in cm _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. what is the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3.1 If yes. 1 2 3 4 888 999 148 . have you been treated in a psychiatric hospital. 1 _ Never 2 _ 1 time 3 _ 2-3 times 4 _ 4 times or more If “Never” (1_).3. or in any other in-patient institution for people with mental problems? (Be sure that you refer to in-patient treatment. in a psychiatric ward of a general hospital. CONTACT WITH HEALTH SERVICES. MENTAL HEALTH 3.

telephone services. an EXAMPLE (based on health services in the Netherlands) is given below for reference. etc.6. Admission: Month/Year 1. polyclinic service Psychiatric service.5 If one or more times in-patient treatment: Could you.).1 3.8. day-care Community Mental Health Care Private psychologist or psychiatrist Consultation service for alcohol and drug related problems 3.8.6 Consultation service for relational and sexual problems 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 1 1 1 1 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 1 2 1 2 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.4 3. e.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. 2.6.6. 1 _ No 2 _ Yes 1 2 888 999 3. Specify: _ _ _ _ _ _ _ _ _ 1 2 888 999 3..1 Page 44 3. etc.3 3. and for which reasons you were admitted? (Please start with the last admission). 4.? 1 _ No 2 _ Yes. how long you stayed there. excessive fear of people in general.6. S.6.5 Psychiatric service.S. depressive feelings. 3. as accurately as possible and for each admission separately describe: when you were admitted. what was the matter with you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 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.6. ______ ______ ______ ______ ______ ______ Length of stay: Months ______ ______ ______ ______ ______ ______ Reason for admission: __________ __________ __________ __________ __________ __________ Out-patient psychiatric treatment and day care 3. codes should include treatment by private psychiatrist. 6.2 3.) (EXAMPLE) 3. other emotions or thoughts that influenced you repeatedly like obsessions.WHO/MSD/MBD/02. anxiety to leave your house.g. to be compelled to clean yourself or your house.O.1 If yes. 5.2 How long have you had this? 555 _ from birth on _ _ (Years) 555 _ _ 888 999 149 .

1 Tobacco products (cigarettes.) 4.1. etc.8 Hallucinogens (LSD. Fiorional. hash.1.2. paint thinner) Sedatives or Sleeping Pills (Valium. spray paint. Morphine. chewing tobacco. gasoline.1 In your life. mushrooms. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 150 . Xanax.10 Other. etc. PDP. how often have you used the substances you mentioned? 4.WHO/MSD/MBD/02. ecstasy. ecstasy.1. Xanax. paint thinner)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 4. etc.6 Inhalants (nitrous. etc.2 If yes to any of these items.7 Sedatives or Sleeping Pills (Valium.2. Quaaludes. ALCOHOL AND DRUG RELATED QUESTIONS 4.1 4.2. grass. in the past three months.9 Heroin. mushrooms. Seconal.2 Alcoholic beverages (beer. diet pills. Quaaludes.3 4. Special K. etc. Librium. Demoral.1.) Inhalants (nitrous. Seconal. gasoline.10 Other. Demoral. spray paint. Dilaudid.4 Cocaine or Crack? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 4 _Weekly 5 _Daily or Almost Daily 5 _Daily or Almost Daily 5 _Daily or Almost Daily 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 4.9 Heroin.5 4. Fiorional.1. etc.2. etc. PDP. etc.) Marijuana (pot.1.1. glue.7 Tobacco products (cigarettes.2.3 Marijuana (pot. Darvon. Dilaudid.) Cocaine or Crack Stimulants or Amphetamines (speed. cigars. etc. Methadone or Pain Medication (codeine.) Alcoholic beverages (beer.) 4. Haldol.) 4.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 4. etc. grass. liquor.6 4.8 Hallucinogens (LSD. etc.2 4.1.2. Percodan. which of the following substances (see DRUG CARD) have you ever used? DRUG CARD 4. etc. acid.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 4. cigars. glue. liquor. Percodan. Librium.1.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 4. chewing tobacco.4 4.2. hash. Darvon.1 Page 45 4. Morphine.2. diet pills. specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 1 _ No 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 2 _ Yes 1 1 1 1 1 1 2 2 2 2 2 2 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 1 _ No 2 _ Yes 1 _ No 2 _ Yes 1 _ No 2 _ Yes 1 _ No 2 _ Yes 1 2 1 2 1 2 1 2 4. wine.2.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 4. etc. Methadone or Pain Medication (codeine.5 Stimulants or Amphetamines (speed.2. etc.)? 1 _Never 2 _Once or Twice 3 _Monthly 4. Haldol.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 5 _Daily or Almost Daily 4. Special K. wine. acid.)? 1 _Never 2 _Once or Twice 3 _Monthly 4 _Weekly 4.1.

15 5.13 5.2 5.1 5.2.4.3.2 5.2.2.5 5.WHO/MSD/MBD/02.? (From “1” = not hopeful/optimistic to “5” = hopeful/optimistic) 5.2. COMMUNITY STRESS AND PROBLEMS 5.8 5.4 In your opinion.2.4 5.………? (From “1” = not close/supportive to “5” = very close/supportive) 5.2.12 5.7 5. how close and supportive of one another are the people of this .4 Neighbourhood? City? Region? Nation? 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 12 12 12 12 3 3 3 3 4 4 4 4 5 5 5 5 888 999 888 999 888 999 888 999 151 .1 5.2.2.16 5.11 5.3.9 5.3 5.2.4.3.14 5.3 How serious do you think the following problems are for your community? (From “1” = not serious to “5” = very serious) Housing Crime Poverty Education Government Family Life Transportation Health Care Job Security Racial Prejudice Pollution Drug Abuse Alcohol Abuse Child and Spouse Abuse Quality of life Physical Security and Safety 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 888 999 In your opinion.3.10 5. how hopeful and optimistic about the future are the people of this ……….1 Page 46 5.4.2.1 5.2.2 5.2.2.6 5.4.2 5.2.2.1 What do you think are some of the major problems facing your community today? (Please use your own words) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________ ________________________________________________ 5.3 5.2.4 Neighbourhood? City? Region? Nation? 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 12 12 12 12 3 3 3 3 4 4 4 4 5 5 5 5 888 999 888 999 888 999 888 999 5.3 5.

In answering these items. Please enter your professional background: _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ 2. Please note any observations you have: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 152 . 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. anthropologist or sociologist because of their training in this kind of research. 1.1 Page 49 Annex 4 COMMUNITY DESCRIPTION SUPRE-MISS INSTRUCTIONS Under the best of circumstances. Please describe your experience in your field shortly: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________________________________________ 3. efforts should be made to use both objective record data and data bases in combination with key informants or focus group members. The questionnaire comprises a broad listing of socio-cultural and community indices and dimensions. the community description should be filled in by a cultural psychologist.Appendix 3 – Qualitative community description questionnaire WHO/MSD/MBD/02.

2. region) _ _ _ _ _ _ _ _ Homeless numbers and rates as an index of social stress _ _ _ _ _ _ _ _ _ _ 1.2 1.1.1. dynamics.WHO/MSD/MBD/02. economic.5.2.4.4.1 Page 50 COMMUNITY DESCRIPTION SUPRE-MISS 1.4.4 Traffic congestion in patient's setting _ _ _ _ _ _ _ _ _ _ Crowding/density in terms of people/location unit (i.3 Describe location via a brief historical chronology (past 10 years) – Include at least 20 entries citing major political.1 Population _ _ _ _ _ _ _ _ _ _ 153 .1. A.1 Pollution problems and changes in pollution for patient’s setting: 1.5 Population Distribution Describe and define: 1.2 1.4.1 1. and changes _ _ _ _ _ _ _ _ _ _ 1.e.1.4 1. and social events: _ _ _ _ _ _ _ _ _ _ Describe socioenvironmental quality via: 1.3 Physical environment _ _ _ _ _ _ _ _ _ _ Define and describe climate _ _ _ _ _ _ _ _ _ _ Urban-rural status.4.1 1. dwelling. 1.4.4..4 Visual _ _ _ _ _ _ _ _ _ _ 1.2 SOCIO-CULTURAL INDICES External Socio-Cultural Context Location Description and History _ _ _ _ _ _ _ _ _ _ Describe community location with regard to: 1.2 Water _ _ _ _ _ _ _ _ _ _ 1.1 Air _ _ _ _ _ _ _ _ _ _ 1.3 1.3 Noise _ _ _ _ _ _ _ _ _ _ 1. neighbourhood.2.4.

see point 1.6.2 Number of single parent households _ _ _ _ _ _ _ _ _ _ 1.000 population.4.. especially with regard to homelife. work.6.3 above) _ _ _ _ _ _ _ _ _ _ Ratio of urban versus rural population for major cities and for the country as a whole.6. Include education institutions at all levels from elementary to college.10.5. _ _ _ _ _ _ _ _ _ _ Patriarchy and matriarchy status. gender..7 1.6 1.3 1.6.6. and/or foreign.10.e.5.g. illness. etc.6 Population parameters (e. Comment particularly on status of women. nuclear. employment.10. age. _ _ _ _ _ _ _ _ _ _ 1.9 1.4 1.3 1.6.5.1 Size or Mean number of people per household _ _ _ _ _ _ _ _ _ _ 1. especially pattern of authority _ _ _ _ _ _ _ _ _ _ Age status and roles _ _ _ _ _ _ _ _ _ _ Migration patterns (In and Out) _ _ _ _ _ _ _ _ _ _ Family organization patterns (i. opportunities.1 Gender status and roles. disliked school. other) _ _ _ _ _ _ _ _ _ _ Marriage and divorce rates. _ _ _ _ _ _ _ _ _ _ Social structure 1.10 Household qualities 1.5 1. extended.. other urban.6.6. and other issues of equality.8 1.2 1. Address the genderization of the society and community.e.6. poverty.2 1.10.6. private and public per 100.1 Page 51 1. religion affiliation) _ _ _ _ _ _ _ _ _ _ Population density (i. poor school performance. ethnicity.6.4 Data on recent migration versus long-term residents from rural.6.3 Number of widow households _ _ _ _ _ _ _ _ _ _ 1. _ _ ________ 1.6. and access _ _ _ _ _ _ _ _ _ _ Percent school dropouts before age 16 and reasons (e.11 Occupational distribution and patterns _ _ _ _ _ _ _ _ _ _ 154 .6.4 1.6.g.. _ _ _ _ _ _ _ _ _ _ Number of schools.WHO/MSD/MBD/02. mean age of marriage _ _ _ _ _ _ _ _ _ _ Educational distribution levels.

16 1. transportation.13 1.14 1.11 Languages spoken _ _ _ _ _ _ _ _ _ _ Ethnic minority population composition/distribution _ _ _ _ _ _ _ _ _ _ Ethnic minority status and empowerment _ _ _ _ _ _ _ _ _ _ Estimated percent literacy _ _ _ _ _ _ _ _ _ _ Ethnic tensions and problems _ _ _ _ _ _ _ _ _ _ C.15 1.10 1.19 GNP for country _ _ _ _ _ _ _ _ _ _ Dominant economic and employment patterns _ _ _ _ _ _ _ _ _ _ Unemployment rates and patterns _ _ _ _ _ _ _ _ _ _ Poverty level distributions _ _ _ _ _ _ _ _ _ _ Housing patterns/styles _ _ _ _ _ _ _ _ _ _ Industry and work patterns _ _ _ _ _ _ _ _ _ _ Percentage of families where both parents work _ _ _ _ _ _ _ _ _ _ Percent expenditures (if available) on food.9 1. Socio-Cultural and Linguistic Describe: 1.8 1.12 1. Social and Economic Structure Describe: 1.22 155 . recreation (to see how money is spent) _ _ _ _ _ _ _ _ _ _ Number of tourists per year _ _ _ _ _ _ _ _ _ _ Number of banks _ _ _ _ _ _ _ _ _ _ Number of registered automobiles _ _ _ _ _ _ _ _ _ _ 1. clothing.WHO/MSD/MBD/02. health. housing.17 1.21 1.20 1.7 1.1 Page 52 B.18 1.

32 1.33 1.34 1.000 population _ _ _ _ _ _ _ _ _ _ Number of mental health professionals (i. temples.e. etc. Communications/Media/Entertainment Describe: 1. or places of religious worship _ _ _ _ _ _ _ _ _ _ Religious rituals and ceremonies regarding death _ _ _ _ _ _ _ _ _ _ E.30 1. nurses).29 1. accessibility. temples.25 1. psychiatrists. and acceptability _ _ _ _ _ _ _ _ _ 1.35 Birth rates _ _ _ _ _ _ _ _ _ _ Life expectancy rates _ _ _ _ _ _ _ _ _ _ Number of western medicine physicians per 100. psychologists. Religious Systems Describe: 1. Health and Medical Dynamics Describe: 1. See also Section H _ _ _ _ _ _ _ _ _ _ Number and types of indigenous healers.28 1.27 Formal religions present in community via churches..WHO/MSD/MBD/02.23 1. _ _ _ _ _ _ _ _ _ _ Religious conflicts among groups _ _ _ _ _ _ _ _ _ _ Religious affiliation patterns and rates _ _ _ _ _ _ _ _ _ _ Number of churches.26 1.1 Page 53 D. Describe availability. social workers.36 156 .24 1.31 Number of newspapers _ _ _ _ _ _ _ _ _ _ Number of TV stations or cable _ _ _ _ _ _ _ _ _ _ Number of radio stations _ _ _ _ _ _ _ _ _ _ Describe most popular (circulation) items and why _ _ _ _ _ _ _ _ _ _ F.

41 1.52 1.37 1.45 Availability of special emergency telephone lines or services for suicide _ _ _ _ _ _ _ _ _ _ Number of hospitals _ _ _ _ _ _ _ _ _ _ Models of illness: Western.50 1.51 1.39 1.49 1. Social/Internal _ _ _ _ _ _ _ _ _ _ Number of deaths per year per 100. Supernatural.1 Page 54 1.47 1.40 1.38 1.48 1.54 Homicidal rates _ _ _ _ _ _ _ _ _ _ Crime rates _ _ _ _ _ _ _ _ _ _ Juvenile crime rates _ _ _ _ _ _ _ _ _ _ Alcohol rates _ _ _ _ _ _ _ _ _ _ Substance abuse rates _ _ _ _ _ _ _ _ _ _ Child and spouse abuse rates _ _ _ _ _ _ _ _ _ _ Prostitution rates _ _ _ _ _ _ _ _ _ _ Number of admissions to psychiatric facilities _ _ _ _ _ _ _ _ _ _ Sexual violence and abuse rates _ _ _ _ _ _ _ _ _ _ 157 .44 1.43 1. Social Deviancy Patterns According to Demographic Markers Describe: 1.42 1.000 population _ _ _ _ _ _ _ _ _ _ Primary causes of death? _ _ _ _ _ _ _ _ _ _ Estimates of smoking rates _ _ _ _ _ _ _ _ _ _ Number of suicides per year in last ten years? _ _ _ _ _ _ _ _ _ _ Sanitation _ _ _ _ _ _ _ _ _ _ Recent epidemics or hysteria episodes _ _ _ _ _ _ _ _ _ _ G.46 1.WHO/MSD/MBD/02.53 1.

59. salary.1 Materialism _ _ _ _ _ _ _ _ _ _ 1.8 Time orientation (past.58.59. clinics. budgets.58. General Sociocultural Context Describe: 1.4 Change _ _ _ _ _ _ _ _ _ _ 1.58. training of mental health personnel _ _ _ _ _ _ _ _ _ _ 1.58. mental health professionals. accessibility. volunteer agencies.57 I.WHO/MSD/MBD/02.2 Individualism _ _ _ _ _ _ _ _ _ _ 1.58.56 1. _ _ _ _ _ _ _ _ _ _ The distribution of mental health resources including issues of availability.58.7 Westernization _ _ _ _ _ _ _ _ _ _ Spirituality _ _ _ _ _ _ _ _ _ _ Collectivism _ _ _ _ _ _ _ _ _ _ Cooperation _ _ _ _ _ _ _ _ _ _ Tradition _ _ _ _ _ _ _ _ _ _ Process _ _ _ _ _ _ _ _ _ _ Intuition _ _ _ _ _ _ _ _ _ _ Traditional _ _ _ _ _ _ _ _ _ _ 1. world views.1 Recent history of natural disaster in community _ _ _ _ _ _ _ _ _ _ 1.55 Mental Health and Wellbeing Resources for mental health including hospitals. _ _ _ _ _ _____ Status.6 Scientism _ _ _ _ _ _ _ _ _ _ 1.3 Competition _ _ _ _ _ _ _ _ _ _ 1.58 Socio-cultural ethos.58.2 Recent history of war or civil disturbances _ _ _ _ _ _ _ _ _ _ 158 .1 Page 55 H.58. and acceptability. and orientations as indexed by the following dimensions: 1.59 Socio-Cultural and Political Stability Try to determine socio-cultural and political stability as indexed by the following dimensions: 1. 1.5 Product _ _ _ _ _ _ _ _ _ _ 1. present.9 Perceptions of death and afterlife _ _ _ _ _ _ _ _ _ _ 1. future) _ _ _ _ _ _ _ _ _ _ 1.58. policies and plans.

59.5 Rapid social-technical change via industry.59.59.59.3 Governmental pattern and stability _ _ _ _ _ _ _ _ _ _ 1.7 Situation with regard to refugees and IDPs _ _ _ _ _ _ _ _ _ _ 159 .4 Levels of government and/or police/justice corruption _ _ _ _ _ _ _ _ _ _ 1.6 Levels of crime and violence related to ethnopolitical strife _ _ _ _ _ _ _ _ _ _ 1.1 Page 56 1. land development _ _ _ _ _ _ _ _ _ _ 1.59. investment.WHO/MSD/MBD/02.

what is the attitude toward suicide today? (For example: euthanasia may be accepted. religion. condemnatory.) ______________________________________________________ ______________________________________________________ 2.WHO/MSD/MBD/02. or position of Catholic Church on suicide as sin) ______________________________________________________ ______________________________________________________ 2. critical.) ______________________________________________________ ______________________________________________________ 2. support) ______________________________________________________ ______________________________________________________ 160 . attitudes toward drinking. anger. or may be seen as a final act of dignity and taking control of one’s life) ______________________________________________________ ______________________________________________________ 2. educational system. 2. attitudes toward women.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.1 What has been the historical cultural attitude toward suicide in your country (or cultural group or community)? That is to say.5 What is the general attitude in your country (cultural group or community) toward a person who commits suicide? (For example: sympathy.4 Within the culture of your country. what have people thought about the act of committing suicide? (For example: ritualized suicide in Japan and India. etc. exposure to toxic pollutants in Eastern Europe) ______________________________________________________ ______________________________________________________ 2.1 Page 57 2. geography/climate.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. SOCIO-CULTURAL CONTEXT OF SUICIDE QUESTIONS It will be necessary to adjust the questions to the population under study. and religion on the act of committing suicide? (For example: absence of sun in Northern European countries. anger. etc.3 What has been the influence of your country’s (cultural group or community) history.

John Donne’s “Self-Homicide”) ______________________________________________________ ______________________________________________________ 161 . avoid family members) ______________________________________________________ ______________________________________________________ 2.9 What references to suicide are found in your country’s (cultural group or community) religion.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. literature. art? (For example: Masada deaths. songs.WHO/MSD/MBD/02. burn body. anger.1 Page 58 2. The Bell Jar.7 What is the general attitude in your country (cultural group or community) toward the family members of the suicide victim? (For example: caring. distrust) ______________________________________________________ ______________________________________________________ 2.

2 If ascertainment is made through a coroner.8 Taking each of the last ten years for which data are available.3 What are the instructions in the Coroner’s Act (or equivalent) that govern or are pertinent to the ascertainment of suicide? ______________________________________________________ ______________________________________________________ 3. please describe the system used (i.5 Suicides _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Accidental deaths _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Deaths with open verdict _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Undetermined deaths _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Homicides _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. 3. To whom is the coroner responsible? What is the current legislation relating to the coroner’s office and functions?): ______________________________________________________ ______________________________________________________ 3. ______________________________________________________ ______________________________________________________ 3. community? ______________________________________________________ ______________________________________________________ 3.4 3.1 CORONER’S QUESTIONS (ASCERTAINMENT OF SUICIDE) Please describe the procedure for the ascertainment of suicide in your country.6. accidental death. what were the numbers for each of the following in your country and community? 3.2 3.5 What options exist for the possible misclassification of suicidal deaths (e. what were the percentages for each of the five major methods of suicide? ______________________________________________________ ______________________________________________________ 162 .6.7 What are the leading methods of suicide in your country/region..6.1 Page 59 3.6.6.g.e.1 3.WHO/MSD/MBD/02.3 3.6 Taking each of the last ten years for which data are available. undetermined death – please specify all options)? ______________________________________________________ ______________________________________________________ 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. open verdict.

Sotsiaalteadused. kultuur ja ühiskond (vaimne tervis. Tervis. meditsiinilised ja psüühilised riskitegurid. abiotsiv käitumine. rahvatervishoid (suitsidaalne käitumine.ee (teadur. Tervishoiu Instituut (MSc rahvatervishoius) Professionaalse Psühholoogia Erakool (psühholoogiline nõustaja) Tartu Ülikool.1968 HARIDUS 2006-2010 2005 2000-2003 1986-1991 1975-1986 Tallinna Ülikool. Õigusteaduskond (dipl iur) Saku Gümnaasium AMETIKOHAD 2001-praegu Eesti-Rootsi Vaimse Tervise ja Suitsidoloogia Instituut (ERSI) www.ja Kaubanduskeskus ITC (jurist) UURIMISVALDKONNAD 1. suitsiidikatse sotsiaalsed.suicidology. suitsiidikatse sooritamist mõjutavad sotsiaal-demograafilised ja psühho-sotsiaalsed tegurid) 163 .07.ELULOOKIRJELDUS ISIKLIKUD ANDMED Nimi: Merike Sisask Sünniaeg: 28. Rahvusvaheliste ja Sotsiaaluuringute Instituut (sotsioloogia doktorant) Tartu Ülikool. alates 2007 tegevdirektor) 2003-2007 Nõustamiskabinet “Sigmund” (psühholoogiline nõustaja) 2002-2007 Saku Päevakeskus (psühholoogiline nõustaja) 1995-2002 Saku Õlletehas (jurist) 1991-1995 Informatsiooni. suitsidaalne käitumine ja mõtlemine. kulu-efektiivsed preventsioonistrateegiad) 2.

Sisask M. Nemes B. Community and health professionals' attitude toward depression: a pilot study in 9 EAAD countries. International Psychogeriatrics 2010. Durkee T. Saving and Empowering Young Lives in Europe (SEYLE): a randomized controlled trial. Bolhari J. depressive feelings and suicidality among Estonian schoolchildren aged 13 to 15 years. Wasserman D. Bertolote JM. Haring C. Sisask M. Gadoros J.518244 4.and middle-income country emergency care settings participating in the WHO SUPRE-MISS study. Carli V. Aasvee K. Leppik L. Crisis 2010. De Silva D. Leppik L. Feldman D. Wu J. Arensman E. Cosman D. Vijayakumar L. Wasserman D. Bertolote JM. Hoven CW. Sisask M. Reynders A. Fleischmann A. Varnik A. Vjayakumar L. Schlebusch L. Sisask M. Wasserman D. Suicide registration in eight European countries: a qualitative analysis of procedures and practices. Crisis 2010. Sisask M. Värnik A.14(1):44-55 164 . Bernik B. Sisask M.PUBLIKATSIOONID Rahvusvahelised eelretsenseerimisega ajakirjad. Repetition of suicide attempts: data from five culturally different low. BMC Public Health 2010. Corcoran P. Familicide and suicide in a case of gambling dependence. International Journal of Social Psychiatry 2010. Dosa A. Szekely A. Kaess M. Bobes J. Reiter-Theil S. De Leo D. Horel AC. DOI: 10. Scheerder G. Kocalevent RD. Postuvan V. Kopp M. Apter A. Värnik P. Värnik A. Gusmão R. Arensman E. 22(8):1337-43 6. Maxwell M. van der Feltz-Cornelis CM. Hegerl U.117/0020764009359742 10. Wasserman C. Marusic D. Laido Z. Sisask M. Nguyen VT.1080/14789949. Meise U. Yur'yev A. Värnik P. Yur'yev A.2010. The International Journal of Social Psychiatry 2010. 2010 (avaldamiseks vastu võetud) 2. Bursztein-Lipsicas C.31(4):194-201 5. Sisask M. tsiteeritud ISI Web of Science poolt 1. Archives of Suicide Research 2010. Brakale R. Sisask M. Yur'yev A. Keeley H. Hegerl U. Sexual behavior. Bolhari J. van Audenhove C. Phillips M. Sisask M. Värnik A. Kõlves K.1177/0020764010387059 3. Värnik P. Kahn JP. Saiz P. Fleischmann A. Resch F. Guillemin F. Heidmets L. Värnik A. Värnik P.10(1):192 9. Balazs J. Sarchiapone M. Journal of Forensic Psychiatry and Psychology 2010. DOI: 10. Anderson A. van Audenhove C. Leppik L. Botega N. Värnik A. DOI:10. Role of social welfare in suicide prevention in Europe. Botega NJ. Samm A.31(3):128-36 7. Ibelshäuser A. Värnik A. Employment status influences suicide mortality in Europe. Social inclusion affects elderly suicide mortality.202:86-92 8. Värnik A. Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study. Giupponi G. Brunner R. Kõlves K. Värnik A. Tooding LM. Coffey C. Forensic Science International 2010.

Kõlves K. Suicidal thoughts and depressive feelings amongst Estonian schoolchildren: effect of family relationship and family structure. Värnik P. Bertolote JM. Drug and Alcohol Dependence 2008. Sisask M.95:129-33 16. De Silva D. Hegerl U. Kopp M. Sisask M. Kõlves K. Internet Comments on Media Reporting of Two Adolescents’ Collective Suicide Attempt.et fireplans intervensjonsprogram mot depresjon og suicidalitet [The „European Alliance Against Depression“ – a four-level intervention programme against depression and suicidality].11. Samm A. Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. Botega N. Nguyen VT. Phillips M. Nemtsov A. Wasserman D. Sisask M. Sisask M. 10(2):268-77 3. Sisask M. Sisask M. Maxwell M. Värnik A. Schmidtke A. Archives of Suicide Research 2005.13(1):12-14 2. Aromaa E. Wasserman D. Sisask M. Kõlves K. Trames 2006. Värnik A. Suicide mortality and political transition: Russians in Estonia compared to the Estonians in Estonia and the population of Russia. Aasvee K.30(3):136-43 14. Pull C. van der Feltz-Cornelis CM.62(6):431-5 15. Nordic Journal of Psychiatry 2008. 35:1467-74 Muud rahvusvahelised eelretsenseerimisega ajakirjad 1.17(3):16270 17. Bouleau JH. Marusic A. Värnik A. Meise U. Kõlves K.19:457-68 12. Samm A. Suicidologi 2008. Malakouti K. Tall K. Wasserman D. Värnik A. Leppik L. Tooding LM. Sisask M. Samm A. De Leo D. European Child & Adolescent Psychiatry 2010. Do suicide survivors respond differently when alcohol abuse complicates suicide? Findings from the psychological autopsy study in Estonia. Arensman E. Vjayakumar L. Värnik A. Massive increase in injury deaths of undetermined intent in exUSSR Baltic and Slavic countries: Hidden suicides? Scandinavian Journal of Public Health 2010. Sisask M. Kõlves K. Severity of attempted suicide as measured by the Pierce Suicidal Intent Scale. Oskarsson H. Yur'yev A. 47(6):869-77 18. Pérez Sola V. Värnik A. van Audenhove C.and middle-income countries. Sisask M. Giupponi G. Psychological Medicine 2005. Factors predicting suicide among Russians in Estonia in comparison with Estonians: case-control study. Wittenburg L. Konstabel K. Gusmäo R. Samm A. Tooding LM. Sisask M. Wasserman D. Cibis A. Värnik A.38(4):395-403 13. von Knorring AL. Ricka R. Croatian Medical Journal 2006. European Alliance Against Depression . European Child & Adolescent Psychiatry 2007.1:87-98 165 . Crisis 2009. Fleischmann A. Characteristics of attempted suicides seen in emergencycare settings of general hospitals in eight low. Wasserman D. Kõlves K. Wasserman D. Värnik A. Kõlves K. Anion L. Schlebusch L. Kõlves K. Children’s Depression Inventory in Estonia: Single items and factor structure by age and gender. Värnik A.

Juhendajad: Aleksander Pulver. 15 aastat teadusuuringuid Eesti-Rootsi Vaimse Tervise ja Suitsidoloogia Instituudis: ülevaade tulemustest.88(3):156-63 2. van Audenhove C. Sisask M. Italy. Tallinn: Tallinna Ülikool. 2008 JUHENDATUD MAGISTRITÖÖD 1.87(2):535-9 3. 2008 3. Kertu Valling. Juhendaja: Merike Sisask. Sisask M. Värnik A. Sotsiaalteaduskond. Kõlves K. Tallinn: Estonian-Swedish Mental Health and Suicidology Institute (ERSI). Ibelshäuser A. Värnik A. 10th World Conference on Injury Prevention and Safety Promotion. Värnik A. Eda Muru. Definitions of suicide and non-fatal suicidal acts. 13th ESSSB. Baltic Suicide Paradox. Värnik A. Hegerl U. Värnik A. 2010 3. Siiri Tõniste. Heidmets L. Rome. Kopp M. Mental health and self-destructive behaviours among adolescents: Preliminary results of SEYLE in Estonia. London. Kõlves K. 2010 4. Aasvee K. Värnik A. Suicide registration procedures and practices in Europe. Kõlves K. Sisask M. Rome. van der Feltz-Cornelis CM. Merike Sisask. Visnapuu P. editors. Samm A. Essential papers on suicidology 19932008. editors. Sisask M.] Eesti Arst 2009. Kocalevent RD. 2010 166 . 13th ESSSB. Värnik A. Värnik P. Laido Z. Sisask M.Eesti teadusajakirjad 1. Värnik A. Sisask M. Italy. 2010 2. 13th ESSSB. Tallinn: Tallinna Ülikool. Värnik A. 2007 2. Sotsiaaltöö Instituut. Kõlves K. 2010 2.] Eesti Arst 2008. UK. Värnik P. Sisask M. Juhendajad: Airi Värnik. Gusmão R. Suitsidaalsus ühiskonnas ja suitsiidikatse sooritamist prognoosivad tegurid. Värnik P. Tallinn: Tallinna Ülikool. 2010 RAHVUSVAHELISED KONVERENTSID 1. Reynders A.83:744-9 Muud teaduspublikatsioonid 1. Tajutud sotsiaalne toetus suitsiidikatse sooritanute hulgas. Depressiivsete ja suitsidaalsete kooliõpilaste seksuaalkäitumine. Merike Sisask. Värnik P. To celebrate the 15th anniversary of ERSI. Sotsiaaltöö Instituut.] Eesti Arst 2004. Rome. Perearstipraksise sidusus vaimse tervise häiretega patsientide puhul. Tallinn: Tallinn University Press. Arensman E. Sisask M. [Suicidality in society and the factors predicting suicide attempt. Employment status and suicide mortality in Europe. Dosa A. Meise U. Leppik L. Yur’yev A. Yur’yev A. Sisask M. Coffey C. Laido Z. [Sexual behaviour of depressive and suicidal Estonian schoolchildren. Suitsiidijuhtumite kajastamine: analüüs Maailma Terviseorganisatsiooni soovituslikest meediajuhistest lähtudes. Italy. [15 years of research at the Estonian-Swedish Mental Health and Suicidology Institute: overview of results.

13th ESSSB. Suicidal thoughts and depressive feelings in the context of family relations among schoolchildren in Estonia. Wasserman D. Kocalevent RD. Samm A. Vijayakumar L. Melbourne. Sisask M. Kõlves K. Phillips M. and the EAAD group. Kõlves K. Ireland. France. Estonia. Berolote JM. 2008. 2010 6. Lucknow. Bolhari J. Värnik A. Sisask M. Yur'yev A. Stockholm. 29th Nordic Congress of Psychiatry (Session: Best research from all countries published in Nordic Journal of Psychiatry in 2006-2008). Sisask M. Hegerl U. Family Homicide-Suicide of a Military Man: a case analysis. 2007. P. Konstabel K. Värnik P. Värnik A. 2008 13. 13th Wonca Europe Conference. Merida. 887 16. Ööpik P. Sweden. Scotland. S10. Sisask M. Trends of male suicides and undetermined deaths in Baltic and Slavic ex-USSR countries. Wasserman D. Grauberg M. Samm A. Schlebusch L. Heidmets L. Värnik A. Kempkens D. Värnik A. 2007 15. Family doctors’ perceived obstacles in caring people with depressive symptoms in Estonia: preliminary results from an international study. De Silva D. Family homicide-suicide of a military man: a case analysis. Rome. Sisask M. Sisask M. Aasvee K. Värnik A. Suicide registration procedures and practices in Europe. Familicide-suicide in a case of gambling dependance: implications for military environment. Subjective psychological well-being WHO-5 in assessment of the severity of suicide attempt: WHO SUPRE-MISS study.2 10. Italy. Sisask M. Kõlves K. 1980-2005. International Military Testing Association (IMTA) Conference. Hegerl U. India. Fleischmann A. Kõlves K. 2007. 2009 7. Nguyen VT. Anderson A. P. Reynders A. Killarney.3. Tooding LM. Glasgow. Scotland. 12th ESSSB. Värnik A. Arensman E. XXIV World Congress of IASP. Värnik A. Meise U. Klopeiner See. VIIIth International Conference on Asian Youth and Childhoods. Laido Z. 2007 14. Mexico. 2009 8. Värnik A. Aasvee K. European Alliance Against Depression (EAAD). Sisask M. 12th ESSSB. Sisask M. Tartu.118 12. OR069 167 .5. Värnik A. Australia. 5th World Conference on the Promotion of Mental Health and the Prevention of Mental and Behavioral Disorders.080 11. Coffey C. Kopp M. Glasgow. Sisask M. NATO Advanced Research Workshop “Wounds of War: Lowering Suicide Risk in Returning Troops”. Dosa A. Sisask M. Sisask M. Paris. Värnik A. 9th World Conference on Injury Prevention and Safety Promotion. Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. Ibelshäuser A. Scotland. De Leo D. 12th ESSSB. Kõlves K. Tooding LM. Brief intervention after attempted suicide: findings from WHO SUPRE-MISS in Estonia. 2008. Gusmão R. van Audenhove C. Maaroos HI. Kõlves K. van der Feltz-Cornelis CM. 2008. Suicide ideation and mental health in relation to family functioning among schoolchildren in Estonia. Värnik A. Glasgow. Värnik A. Austria. Kalda R. 2008 9. Botega N.

Psychiatria Danubina 2006. XXII World Congress of IASP. De Leo D. Psychiatria Danubina 2006. 18(Suppl 1). Värnik A. 2007. Denmark.17. Portorož. Slovenia. Psychiatria Danubina 2006. Botega N. Fleischmann A. Sweden. Sisask M. PO22 26. Portorož. Värnik A. 11th ESSSB. Sisask M. South-Korea. Bolhari J. 2002. Vihula. England. Kõlves K. Gender differences in public attitude about depression. 10th ESSSB. Narva-Jõesuu. Wasserman D. Kõlves K. Slovenia. Fleischmann A. Väsimuse mõju teismeliste vaimsele tervisele. Värnik A. 2008 4. Värnik A. Killarney. Phillips M. Copenhagen. Kõlves K. Värnik A. Wasserman D. Stockholm.ja Terviseteaduste Keskuse IX Aastakonverents. Wasserman D. 62 22. 1st Asian Regional Conference on Safe Communities. Värnik A. 11th ESSSB. Kõlves K. Slovenia. 2003. Stockholm. Vijayakumar L. Suitsiidide registreerimine ning selle mõju ebaselge tahtlusega surmade arvukusele. 18(Suppl 1). Värnik A. Raudsepp J. Nguyen VT. 9th ESSSB. Schlebusch L. Teepalu K. Vijayakumar L. Wasserman D. Sisask M. Portorož. Wasserman D. Värnik A. Bolhari J. Berolote JM. Lepanina. Sisask M & SEYLE grupp. 41 21. Sweden. Ireland. Slovenia. Värnik A. Sisask M. De Leo D. Värnik P. Eesti Käitumis. Sisask M. 102:3 24. De Silva D. 11th ESSSB. De Silva D. Pruul P. Eesti Käitumis. The prevalence of depressive symptoms in schoolchildren in Estonia. 18(Suppl 1). Värnik A.1 23. Wasserman D. Sisask M. Suicide prevention in a post-soviet society: case of Estonia. 110:1 25. 117 19. Sisask M. Vijayakumar L. 2002. von Knorring AL. 18(Suppl 1). Warwick. Suwon. Wasserman D. Värnik A. Rieger MA. Sisask M. Botega NJ. Wasserman D. Maaroos HI. Berolote JM. Nguyen 168 . Opportunities and obstacles of depression treatment in primary care. 11th ESSSB. T3B KONVERENTSID EESTIS 1. Sisask M. Schlebusch L. Tihaste M. Phillips M. Religioossus kui kaitsetegur suitsiidikatse vastu: WHO SUPRE-MISS juhtkontroll uuring. XXII World Congress of IASP. Bertolote JM. Samm A. Värnik A. SUPRE-MISS in Estonia – main risk groups among suicide attempters. Laido Z. PO7.ja Terviseteaduste Keskuse VIII Aastakonverents. 2010 3. XXIV World Congress of IASP. Kõlves K. Sisask M. Psychiatria Danubina 2006. Sisask M. Sisask M. Eesti Käitumisja Terviseteaduste Keskuse VII Aastakonverents. OR022 18. WHO SUPRE-MISS: Rehabilitation for suicide attempters. Bolhari J. 2010 2. Botega N. Factors predicting suicide among Estonian Russians and Estonians. Portorož. 116 20. Does religion pretect against suicide attempt: WHO SUPRE-MISS study. Internet comments on media reporting of a suicide attempt. 2003. Kempkens D. Suicidal behaviour among young people in Estonia: A case analysis. 2004. Värnik A. Sisask M.

WHO SUPRE-MISS: Suitsiidikatse sooritanute psüühiline terviseseisund ja kontakt tervishoiuasutustega. Fleischmann A. 2004 Sisask M. WHO-SUPRE: Ülemaailmne suitsiidikatsete uuring Eestis. Värnik A. Suitsiidikatse kajastamine meedias ja sellelejärgnenud Interneti kommentaarid. 2004 Sisask M. Värnik A. Värnik A.ja Terviseteaduste Keskuse V Aastakonverents. Võru-Kubija. Pühajärve. Eesti Käitumis. Toila. 2007 Sisask M. Samm A. Tartu. 10. Eesti Sotsiaalteaduste V Aastakonverents. VT.ja Terviseteaduste Keskuse VI Aastakonverents. Värnik A. 9. Kahe teismelise ühise suitsiidikatse kajastamine meedias ja sellele järgnenud Interneti kommentaarid. 2005 Sisask M. Värnik A. Eesti Käitumis. Raudsepp J. 2003 169 . Anion L.ja Terviseteaduste Keskuse IV Aastakonverents. Eesti Käitumis. Kõlves K. Subjektiivne psühholoogiline heaolu suitsiidikatse raskusastme määratlemisel. 6. 7.ja Terviseteaduste Keskuse II Aastakonverents. Eesti Käitumis. 8. Pärnu. Depressioon ja suitsidaalsus: avalikkuse hoiak ja teadlikkus. Eesti Käitumis.ja Terviseteaduste Keskuse III Aastakonverents. Tallinn. Värnik A. 2005 Sisask M. Kõlves K. Suitsiidikatse raskusastme määratlus ja selle seos psüühilise seisundiga.5. 2006 Sisask M. Eesti Sotsiaalteaduste VI Aastakonverents. Roosta.

Public Health Science (suicidal behaviour. socio-demographic and psycho-social factors of attempted suicide) 170 .1968 EDUCATION 2006-2010 Tallinn University. suicidal behaviour and ideation. Department of Public Health (MSc in public health) 2000-2003 The Private School of Professional Psychology (psychological counsellor) 1986-1991 University of Tartu. cost-effective prevention strategies) 2. medical and psychic factors of attempted suicide. Law Faculty (dipl iur) 1975-1986 Saku Gymnasium PROFESSIONAL POSITIONS 2001-present Estonian-Swedish Mental Health and Suicidology Institute (ERSI) www. Culture and Society (mental health.07. 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.CURRICULUM VITAE PERSONAL DATA Name: Merike Sisask Date of birth: 28.ee (researcher. Social Sciences. help-seeking behaviour. social. Institute of International and social studies (PhD student in sociology) 2005 University of Tartu.suicidology.

Brakale R. The International Journal of Social Psychiatry 2010. De Leo D.31(3):128-36 7. Värnik A.117/0020764009359742 10. Repetition of suicide attempts: data from five culturally different low. Cosman D. Hoven CW. Gadoros J. Nguyen VT. Tooding LM. Sisask M. Sisask M. Anderson A. De Silva D. Fleischmann A. Sisask M. Wasserman C. Coffey C. Yur'yev A. Nemes B. Maxwell M. Schlebusch L. Leppik L.31(4):194-201 5.518244 4. International Psychogeriatrics 2010. Kocalevent RD. Crisis 2010. Brunner R. Värnik A. Kahn JP. depressive feelings and suicidality among Estonian schoolchildren aged 13 to 15 years. Botega N. Hegerl U. Arensman E. Fleischmann A. Phillips M. Leppik L. Hegerl U. Archives of Suicide Research 2010. Samm A. Saving and Empowering Young Lives in Europe (SEYLE): a randomized controlled trial.14(1):44-55 11. Sexual behavior. Sisask M. Community and health professionals' attitude toward depression: a pilot study in 9 EAAD countries. Arensman E. DOI:10. Dosa A. Bernik B. Värnik P.2010. Bertolote JM. Reiter-Theil S. Kopp M. Wasserman D. van Audenhove C. Carli V. Värnik P. Postuvan V. Crisis 2010. Social inclusion affects elderly suicide mortality. Gusmão R. Värnik A. Vjayakumar L. Suicide registration in eight European countries: a qualitative analysis of procedures and practices. Sisask M. Heidmets L. van der Feltz-Cornelis CM. Botega NJ. BMC Public Health 2010. van Audenhove C. Guillemin F. 2010 (accepted) 2. DOI: 10. Samm A. Aasvee K. Keeley H.and middle-income country emergency care settings participating in the WHO SUPRE-MISS study. Bobes J. International Journal of Social Psychiatry 2010. Sisask M. Tooding LM.10(1):192 9. 22(8):1337-43 6. Resch F. Feldman D. Balazs J. Sisask M. Horel AC. Bolhari J. Värnik A. Värnik A.202:86-92 8. Kõlves K. Sisask M. Kaess M. Journal of Forensic Psychiatry and Psychology 2010. Bertolote JM. Reynders A. Kõlves K. Wasserman D. Yur'yev A. Sarchiapone M. Värnik A. Värnik A. Kõlves K.1177/0020764010387059 3. Durkee T.PUBLICATIONS International peer-reviewed journals cited in ISI Web of Science 1. Employment status influences suicide mortality in Europe. Bolhari J. Värnik A. Marusic D. Värnik P. Haring C. Wu J. Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study. Szekely A. Sisask M. Leppik L. Yur'yev A. Varnik A. Bursztein-Lipsicas C. Scheerder G. Aasvee K.1080/14789949. Värnik P. Laido Z. Suicidal thoughts and depressive feelings amongst Estonian schoolchildren: effect of 171 . Sisask M. Ibelshäuser A. Giupponi G. Wasserman D. Sisask M. Vijayakumar L. Värnik A. Familicide and suicide in a case of gambling dependence. Corcoran P. Saiz P. Forensic Science International 2010. Meise U. Apter A. DOI: 10. Role of social welfare in suicide prevention in Europe.

Samm A. Massive increase in injury deaths of undetermined intent in exUSSR Baltic and Slavic countries: Hidden suicides? Scandinavian Journal of Public Health 2010. Sisask M. Nguyen VT. Sisask M. Do suicide survivors respond differently when alcohol abuse complicates suicide? Findings from the psychological autopsy study in Estonia. Severity of attempted suicide as measured by the Pierce Suicidal Intent Scale. Wittenburg L. Värnik A. De Leo D. Bouleau JH. Kõlves K. 13. Värnik A. 15.12. Hegerl U. 35:1467-74 Other international peer-reviewed journals 1. Gusmäo R. Tooding LM. Trames 2006. Wasserman D.95:129-33 Samm A. Wasserman D. Samm A.19:457-68 Värnik P. Suicide mortality and political transition: Russians in Estonia compared to the Estonians in Estonia and the population of Russia.and middle-income countries. Kõlves K. Children’s Depression Inventory in Estonia: Single items and factor structure by age and gender.30(3):136-43 Sisask M. Sisask M. van der Feltz-Cornelis CM. Archives of Suicide Research 2005. De Silva D. Giupponi G.62(6):431-5 Tall K. European Child & Adolescent Psychiatry 2007. Malakouti K. Drug and Alcohol Dependence 2008. Marusic A. 17.17(3):16270 Kõlves K.1:87-98 172 . Yur'yev A. van Audenhove C. Sisask M. Kõlves K.13(1):12-14 2. Värnik A. Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt. Sisask M. 47(6):869-77 Fleischmann A. Internet Comments on Media Reporting of Two Adolescents’ Collective Suicide Attempt. Aromaa E. 14. Croatian Medical Journal 2006. family relationship and family structure. von Knorring AL. Anion L. Värnik A. Wasserman D. Arensman E. Kopp M. Pull C. Schmidtke A. Wasserman D. 10(2):268-77 3. Factors predicting suicide among Russians in Estonia in comparison with Estonians: case-control study.et fireplans intervensjonsprogram mot depresjon og suicidalitet [The „European Alliance Against Depression“ – a four-level intervention programme against depression and suicidality]. Värnik A. Värnik A. 16. Vjayakumar L. Leppik L. Värnik A. Nordic Journal of Psychiatry 2008. Bertolote JM. Ricka R. European Alliance Against Depression . Nemtsov A. Wasserman D. Kõlves K. Oskarsson H. Characteristics of attempted suicides seen in emergencycare settings of general hospitals in eight low. Kõlves K. Cibis A. Schlebusch L. Crisis 2009. Suicidologi 2008. Sisask M. Phillips M. Värnik A. Maxwell M. Sisask M. 18. Konstabel K. Kõlves K. Pérez Sola V.38(4):395-403 Sisask M. Botega N. European Child & Adolescent Psychiatry 2010. Meise U. Sisask M. Wasserman D. Psychological Medicine 2005.

Hegerl U. 10th World Conference on Injury Prevention and Safety Promotion. 2008 3. Värnik A. [Perceived social support among suicide attempters. London. Sisask M. Sisask M. Sisask M. Kertu Valling. 2010 INTERNATIONAL CONFERENCES 1. Värnik A. Perearstipraksise sidusus vaimse tervise häiretega patsientide puhul. Dosa A. Värnik A. Italy.83:744-9 Other scientific publications 1. Aasvee K. Kocalevent RD. Kõlves K. Värnik A. 15 aastat teadusuuringuid Eesti-Rootsi Vaimse Tervise ja Suitsidoloogia Instituudis: ülevaade tulemustest. Laido Z. Sisask M. 2007 2. Samm A. Eda Muru. Kõlves K. van Audenhove C. Social Department. Sisask M. Rome. Tallinn: Estonian-Swedish Mental Health and Suicidology Institute (ERSI).] Eesti Arst 2008. Visnapuu P. Tallinn: Tallinn University. van der Feltz-Cornelis CM. Merike Sisask. To celebrate the 15th anniversary of ERSI. Värnik P. Sisask M. 2010 173 . Sisask M. Suitsidaalsus ühiskonnas ja suitsiidikatse sooritamist prognoosivad tegurid. Sisask M. Värnik P. Tallinn: Tallinn University. [Reporting of suicide cases: analysis based on the World Health Organization media guidelines. Kõlves K. Depressiivsete ja suitsidaalsete kooliõpilaste seksuaalkäitumine. Italy. Merike Sisask. [The coherency between general practice and social work in case of patients with mental disorders. Rome.] Eesti Arst 2009. Siiri Tõniste. Tallinn: Tallinn University Press. Reynders A. [Sexual behaviour of depressive and suicidal Estonian schoolchildren. [Suicidality in society and the factors predicting suicide attempt. UK. Värnik A.] Supervisor: Merike Sisask.] Supervisors: Aleksander Pulver. Värnik A. Definitions of suicide and non-fatal suicidal acts.88(3):156-63 2. 2010 3. Kopp M. Kõlves K. Suitsiidijuhtumite kajastamine: analüüs Maailma Terviseorganisatsiooni soovituslikest meediajuhistest lähtudes. Suicide registration procedures and practices in Europe. editors. Heidmets L.] Eesti Arst 2004. Ibelshäuser A. Arensman E. Tajutud sotsiaalne toetus suitsiidikatse sooritanute hulgas. Värnik P.Estonian scientific journals 1. Essential papers on suicidology 19932008. [15 years of research at the Estonian-Swedish Mental Health and Suicidology Institute: overview of results. Institute of Social Work. Laido Z. Yur’yev A. 2010 2. Mental health and self-destructive behaviours among adolescents: Preliminary results of SEYLE in Estonia. 2008 SUPERVISED DISSERTATIONS (MASTER’S THESIS) 1. Meise U. Tallinn: Tallinn University. 2010 2. Coffey C. 13th ESSSB. Institute of Social Work.87(2):535-9 3. Baltic Suicide Paradox. Värnik A.] Supervisors: Airi Värnik. editors. 13th ESSSB. Värnik A. Gusmão R.

Suicidal thoughts and depressive feelings in the context of family relations among schoolchildren in Estonia. Berolote JM. Kõlves K. Sisask M. Aasvee K. Schlebusch L. Samm A. 13th ESSSB. Leppik L. 12th ESSSB. Melbourne. Family homicide-suicide of a military man: a case analysis. Kocalevent RD.