Examining Suicide from a Population Health Perspective
By Matt Wray, PhD, MA, an associate professor of sociology at Temple University and an alumnus of the Robert Wood Johnson Foundation Health & Society Scholars program (2006-2008). His research and teaching interests include the social determinants of health, cultural sociology, and the sociology of race and ethnicity. This post is part of a series on the RWJF Health & Society Scholars program, running in conjunction with the program’s tenth anniversary. The RWJF Health & Society Scholars program is designed to build the nation’s capacity for research, leadership and policy change to address the multiple determinants of population health.
Consider two recent suicides that made headlines around the globe: In January of 2011, after authorities confiscated his belongings, beat and humiliated him, Mohamed Boazizi set himself ablaze in frustration and protest. Boauzizi was a 26-year-old fruit vendor, scratching out just enough money to feed a family of eight, despite unchecked harassment by local authorities. His self-immolation after harassment at the hands of Tunisian authorities helped trigger the Tunisian Revolution, and in turn, the Arab Spring.
In April 2012, Dmitris Christoulis, a 77-year old retired pharmacist in Athens, shot himself outside the Greek Parliament building, in what the New York Times described as "despair over his financial problems [in] this austerity-weary country." Greek media reported that he suffered from health problems and struggled to pay for his medications. He left a suicide note saying he could not face "scavenging through garbage bins for food and becoming a burden to my child.”
Here in the United States, in 2009, the last year for which data are available, some 37,000 Americans died by their own hands, making suicide the tenth leading cause of death in the nation and the fourth leading cause for adults ages 18 to 65. By any standard, suicide is a public health problem. Nevertheless, much of the public discourse and, for that matter, much of the research about suicide focuses on individual mental health problems. We need that discussion and research, but we need also to remember that mental health problems are not the only possible causes of suicide that we need to explore. Suicides can and do arise from factors apparently unrelated to victims' psychological problems. In Christoulis' and Bouazizi's deaths, dire economic and political conditions—not individual psychological problems—appear to have been primary causes.
The focus on psychological and biological causes of suicide, to the near exclusion of economic, political, and other social factors, is evidence that we've come to view suicide almost solely through the lens of the “psych” disciplines. Such analysis is useful, to be sure, and it has led to important innovations in suicide research such as the psychological autopsy. But it largely ignores a significant part of the picture.
Fortunately, another line of research considers suicide in a more holistic fashion, asking how local contexts and communities affect suicide rates over time. From this line of inquiry, we learn that even if it is true that most people who kill themselves are experiencing acute psychological distress, the causes of their distress are often social or economic, rather than psychological or neurochemical.
What the research tells us is that a number of social factors are correlated with suicide rates, including such economic indicators as unemployment rates, poverty rates, and various other measures of hardship. A number of social and political indicators are also correlated with suicide, including levels of urbanization and degrees of social cohesion in a community. So, for example, communities with high levels of fragmentation—that is, high divorce rates, high levels of residential turnover, and low levels of home ownership—have higher suicide rates.
The question we need to answer is exactly why these things travel together. The best answer we have so far is that such economic, political and social factors are all fundamentally related, in the sense that they are all indicators of low levels of social integration. As Emile Durkheim, the father of sociology, observed in the 19th century, when we are disconnected from others, we are at higher risk for self-destruction.
Such disconnectedness robs people of the supports they need to weather personal or economic storms. They have fewer trusted relationships, fewer social ties and less social support. In stable periods of their lives, they may be relatively ok. But when personal crises arise, they may quickly feel hopeless, isolated, and alone, with no apparent path out of their suffering. In such cases, suicide may begin to look not like a problem, but a solution.
But again, this may have less to do with psychological and biological traits and characteristics and more to do with how the communities, groups, and networks we live in are structured and experienced. It is telling, for example, that different demographic groups have different suicide rates. Suicide rates are highest among white males and Native Americans and lowest among women of color—and not by a little. Such racial and gender disparities are both pronounced and persistent in the United States.
Why is that? I've spent years examining the issue, and I am unaware of any psychological or biological evidence or reasoning that explains the disparities.
That's a sure indicator that we need to examine the problem from a population health perspective. And a good place to start is by following the trail Durkheim blazed: looking at levels of isolation and cohesiveness as they vary from one group to the next. For example, we should find out whether, generally speaking, white men are more socially isolated than black females.
Finally, it's not just during tough economic and political times that a better understanding of the causes of suicide would be useful. To the contrary, what these trying times in the United States and around the world show us is just how badly we need suicide research that focuses on social contexts as contributing factors.