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Male depressive traits in relation to violent suicides or suicide attempts: A systematic review
Journal of Affective Disorders 262 (2020) 55–61
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Review article
Male depressive traits in relation to violent suicides or suicide attempts: A systematic review Emil Heilmann Sørensena,b, Mette Viller Thorgaardb,c, Søren Dinesen Østergaardb,c,
T
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a
Horsens Regional Hospital, Horsens, Denmark Department of Clinical Medicine, Aarhus University, Aarhus, Denmark c Department of Affective Disorders, Aarhus University Hospital, Aarhus, Denmark b
A B S T R A C T
Background: : Male sex is a consistently reported risk factor for violent suicide. It has been suggested that this association may be driven by so-called male depression - as operationalized by the Gotland Male Depression Scale (GMDS). The aim of this systematic review was to investigate if males dying by or attempting suicide with violent methods, display symptoms compatible with male depression. Methods: : This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search of PubMed, Embase and PsycINFO was performed using search terms covering: male sex, violent suicide/suicide attempt, and symptoms of male depression from the GMDS. Subsequently, a qualitative synthesis of studies meeting predefined inclusion criteria was carried out. Results: : A total of 28 studies reporting on 91,933 violent suicides and 113 violent suicide attempts were included in the qualitative synthesis. The suicide/suicide attempt methods reported in these studies were predominantly shooting, hanging or drowning. The only two symptoms from the GMDS that was reported in relation to violent suicides/suicide attempts was overconsumption of alcohol or drugs and suicide attempts in the biological family. No studies had systematically assessed suicide victims or attempters for symptoms of male depression. Limitations: : Publication-, selection-, and information biases may have affected this review. Conclusions: : Symptoms of male depression are rarely reported in relation to violent suicides/suicide attempts. The most likely explanation for this finding is that there has been little focus on this potential association. Future studies should address this void.
1. Introduction Suicide is responsible for approximately 800,000 deaths worldwide every year according to the World Health Organization and is now the second leading cause of death among the 15–29 year old (WHO, 2019a). Mental disorders – and major depression in particular – are strong risk factors for suicide, with nearly two thirds of people dying by suicide suffering from a depressive disorder (Henriksson et al., 1993; WHO, 1993). Although there is a strong association between mood disorder and suicide, the majority of individuals with a mood disorder does not die by suicide (Pompili et al., 2009; Rihmer, 2007), and identifying those at high risk of suicide is therefore instrumental to allow for effective prevention (Olfson et al., 2017; Nordentoft, 2007). Another consistently reported risk factor for suicide is male sex. Specifically, the global male-to-female ratio of age-standardized suicide rate was 1.8 in 2016 (WHO, 2019b). This is somewhat paradoxical given that major depression is approximately twice as prevalent among females (Ayuso-Mateos et al., 2001; Sjoberg et al., 2017) and that suicide attempts are also much more common among females compared to males (Poma et al., 2013; Weissman et al., 1999). There are probably
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several (potentially interacting) explanations for this apparent paradox. First, males are less likely to seek help when in psychological distress (Hartley and Petersen, 1993; Moller-Leimkuhler, 2002). Second, when males attempt suicide they use more violent methods than females (Persett et al., 2018; Bilban and Skibin, 2005) such as hanging, use of a firearm or jumping from heights (Rihmer et al., 1995; Giner et al., 2014), and alcohol is often involved (Bilban and Skibin, 2005). Third, it has been suggested that the prevalence of depression among males is probably equivalent to that among females, but that depression in males typically manifests in a different manner (Rutz et al., 1995). Therefore, this alleged “male depression” does often not meet the criteria for major depression (Zierau et al., 2002) as operationalized in the major diagnostic guidelines (American Psychiatric Association, 2013) and consequently often goes undetected and untreated - which may ultimately lead to suicide (Rutz et al., 1995). A recent study supporting this hypothesis is that by Ostergaard, which demonstrated that the male-female suicide ratio in Denmark has increased quite dramatically over the past three decades (from 1.75 to approximately 2.75) during which the absolute number of suicides was approximately halved (Ostergaard, 2018). These coinciding developments are compatible
Corresponding author at: Department of Affective Disorders, Aarhus University Hospital, Palle Juul Jensens Boulevard 175, 8200 Aarhus N. E-mail address: [email protected] (S.D. Østergaard).
https://doi.org/10.1016/j.jad.2019.10.054 Received 13 August 2019; Received in revised form 9 September 2019; Accepted 28 October 2019 Available online 30 October 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
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with the existence of male depression - since the drop in the total number of suicides during this period of time is at least partly driven by improved care and treatment of major depression, whereas the male depressions are more likely to have gone undetected and untreated (Ostergaard, 2018). The male depression concept stems from the so-called Gotland study in which general practitioners on the Swedish island of Gotland received education in diagnosing and treating major depression (Rutz et al., 1992; Rutz et al., 1989). This education program led to significantly increased use of antidepressants, while the rate of hospital admissions for depression and suicides was reduced (Rutz et al., 1992; Rutz et al., 1989). In a follow-up analysis it was demonstrated that the reduced suicide rate on Gotland was driven entirely by reductions in female suicides, while the rate of male suicide remained virtually unaffected (Rutz et al., 1995). This observation led Rutz et al. to propose the existence of a particular type of depression (Rutz et al., 1995) that mainly affected males, and which they later operationalized in the Gotland Male Depression Scale (GMDS) (Zierau et al., 2002). According to the GMDS (see Appendix 1 in the supplementary material), the symptom definition of male depression differs from that of classical major depression, by also considering symptoms such as irritability, aggressiveness, lowered stress threshold, low impulse control, restlessness, substance abuse, acting-out behavior and family history of suicide attempts/proneness to dangerous behavior (Zierau et al., 2002). Prior studies have suggested that male depression (higher scores on the GMDS) are linked to suicide proneness among psychiatric inpatients (Innamorati et al., 2011; Pompili et al., 2012). When considering i) the symptoms defining male depression (irritability, aggressiveness, lowered stress threshold, low impulse control, restlessness, substance abuse, and acting-out behavior) (Zierau et al., 2002), ii) the proposed link between male depression and suicide proneness (Innamorati et al., 2011; Pompili et al., 2012), and iii) the fact that males tend to use violent means when attempting suicide (Persett et al., 2018; Bilban and Skibin, 2005), it seems quite likely that male depression is linked to violent suicides/suicide attempts. Therefore, the aim of this systematic review was to determine whether symptoms compatible with male depression are prevalently reported for males who die by violent suicides or attempt suicide with a violent method. If this is the case, it emphasizes the need to take the male depression phenotype seriously. If not, it is most likely a consequence of there having been little focus on this association in the field – and calls for further studies on this specific topic.
"Behavioral Symptoms"[Title/Abstract] OR "Aggression"[Title/Abstract] OR male depressi*[Title/Abstract] OR "acting out"[Title/Abstract] OR substance related disorder*[Title/Abstract])))) AND ("Suicide"[Mesh] OR suicid*)) AND ("Men"[Mesh] OR men OR male)) Filters: English”. Equivalent searches of Embase and PsycINFO were conducted (see the search strings in the supplementary material).
2. Methods
2.3. Post hoc decision regarding alcohol and drug use in relation to violent suicide/suicide attempts
2.2. Inclusion criteria Studies were included in the qualitative synthesis if meeting all of the following criteria: 1 Containing original data on completed suicides or suicide attempts using violent methods (e.g. shooting, hanging, jumping from heights and/or drowning). 2 Containing data on males (in case of studies that included data on females, specific data on males was required for inclusion). 3 Covering symptoms compatible with the male depressive syndrome (that are not part of the major depressive syndrome) as operationalized by the GMDS. 4 Using English language and published in a journal with peer review (the latter to ensure sufficient quality of the reported data). Single case studies and systematic reviews were not included. The screening and selection of literature was conducted independently by EHS and MVT. Initially, the identified records were screened for eligibility based on title and abstract. When title and abstract indicated that a record could be eligible for inclusion, the full-text version of the article was retrieved and evaluated. If the full-text version of the article indicated that the study had led to results that were eligible for inclusion, but that these results were not included in the article, an e-mail was sent to the author, asking for access to the results in question. These results were then reviewed for eligibility. The references of included articles were independently screened for further relevant records by EHS and MVT. Any disagreement regarding eligibility was initially discussed between EHS and MVT. If an agreement was not reached, SDØ was consulted and a final decision regarding inclusion was made. The following information was extracted from all included articles: publication year, setting (country), study design, sample size (number of violent suicides/suicide attempts), reported symptoms of male depression, (attempted) suicide method, and main results (focusing on symptoms compatible with the male depressive syndrome).
2.1. Search string During our screening of the literature, we discovered that while the search appeared to have systematic coverage for the symptoms of male depression in general, there was one exception to this rule. Specifically, we found that the search did not cover all studies of violent suicides/ suicide attempts in relation to which the victim had ingested alcohol or drugs. Since there is a quite large body of literature on the association between consumption of psychoactive substances and suicide in general (Borges et al., 2017; Borges and Loera, 2010), covering this aspect in the context of male depression seems somewhat futile. Also, consumption of alcohol and pills in relation to suicides/suicide attempts can rightfully be regarded as an acute means to become sufficiently serene to carry out the act (Borges et al., 2017; Borges and Loera, 2010) – rather than an underlying symptom of male depression. For these reasons, we decided that we would i) not expand the search to fully cover the literature on the intake of alcohol/pills/drugs of abuse in relation to violent suicides/suicide attempts, ii) report the results on this association as identified via our original search strategy, and iii) that the qualitative synthesis of our review would have relatively little emphasis on this association, which is already well established. Rather, we decided to focus on the other symptoms of male depression in
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline (Moher et al., 2009). The databases PubMed, Embase and PsycINFO were systematically searched for relevant literature on February 5th, 2019. The search string used for PubMed was as follows: “(((("Firearms"[Mesh] OR "Wounds, Gunshot"[Mesh] OR "Drowning"[Mesh])) OR ((firearm*[Title/Abstract] OR Gunshot[Title/Abstract] OR gun[Title/Abstract] OR guns[Title/Abstract] OR shoots [Title/Abstract] OR shooting[Title/Abstract] OR drown*[Title/Abstract] OR hang*[Title/Abstract] OR jump*[Title/Abstract] OR violent suicide*)))) AND (((((("Frustration"[Mesh] OR "Irritable Mood"[Mesh] OR "Burnout, Professional"[Mesh] OR "Affective Symptoms"[Mesh] OR "Behavioral Symptoms"[Mesh:noexp] OR "Aggression"[Mesh:noexp] OR "Acting Out"[Mesh] OR "Substance-Related Disorders"[Mesh] OR "Lethargy"[Mesh])) OR (("frustration"[Title/Abstract] OR "self-pity"[Title/ Abstract] OR "indecision"[Title/Abstract] OR "emptiness"[Title/Abstract] OR "Irritable Mood"[Title/Abstract] OR "irritability"[Title/Abstract] OR "lethargy"[Title/Abstract] OR "burnout"[Title/Abstract] OR "burn out"[Title/Abstract] OR "Affective Symptoms"[Title/Abstract] OR 56
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Idenficaon
PubMed n = 279
Embase n = 217
PsycINFO n = 153
Records idenfied through database searches n = 649 Duplicates removed n = 86
Screening
Records screened via tle and abstract n = 563
Records excluded if inclusion criteria were not fulfilled n = 344
Included
Eligibility
Full-text arcles reviewed for eligibility n = 219 Full-text arcles excluded if inclusion criteria were not fulfilled n = 199
Screening of references of included arcles and the grey literature
Arcles included via inial screening n = 20
Arcles included via screening n=8
Arcles included in qualitave synthesis n = 28
Fig. 1. Flowchart illustrating the screening and selection of literature.
whether results meeting the eligibility criteria were available. The authors of these 49 studies were contacted and upon review of the response/data sent by these authors (or lack of response), further 45 studies were excluded. The remaining 20 articles were included in the review. The references from the 20 included articles were screened for eligibility, resulting in inclusion of another eight articles. The screening of the grey literature did not result in further inclusion. Hence, a total of 28 articles were included in the qualitative synthesis. The characteristics of the 28 included studies are outlined in Table 1. The studies were published in the period from 1970 to 2018 and reported data on 92,046 males from 14 countries (11 studies with data from the United States). Apart from two studies, namely the cohort study by Mukamal et al. (2007) and the case control study by Bhatt et al. (2018), all studies were cross-sectional and the vast majority of those were based on data from autopsies. There were 24 studies on completed violent suicide (n = 91,933) and four on violent suicide attempts (n = 113). In terms of the violent suicide/suicide attempt methods, eight of the studies reported data exclusively regarding
relation to violent suicides/suicide, where the association is less/not established. 3. Results The literature screening process is illustrated in Fig. 1. A total of 649 records were identified in PubMed, Embase and PsycINFO. After removal of duplicates (n = 86) using Endnote, the 563 remaining records were initially screened based on title and abstract following which 344 records were excluded because they did not meet the inclusion criteria. Full-text versions of the remaining 219 records were retrieved and screened for eligibility. Of these, 154 articles were excluded, either because they did not meet the inclusion criteria (n=152), or if the data in the articles had already been included via other articles (n = 2). The latter was the case for the data presented in Ahlm et al. (2015) and in Shields et al. (2007) al. (Ahlm et al., 2015) Shields et al., 2007), which was included via the larger studies by the same research groups (Ahlm et al., 2013; Shields et al., 2006). For 49 articles, it was unclear 57
Cross-sectional. 9 males. Cross-sectional. 24 males.
Cross-sectional. 17 males. Cross-sectional. 95 males. Cross-sectional. 27 males. Cross-sectional.54 males. Cross-sectional. 14 males. Cross-sectional. 14 males. Cross-sectional. 6 males. Cross-sectional. 28 males. Cohort study. 78 males.
Geertinger and Voigt, 1970 Denmark and Sweden Kost-Grant, 1983 USA
Peterson et al., 1985 USA
58
Selvaraj and Sadasivam, 2017 India
Choi et al., 2017 USA
Haw and Hawton, 2016 England
Jones et al., 2013 Sweden
Tormey et al., 2013 Ireland
Kaplan et al., 2013 USA
Ahlm et al., 2013 Sweden
Zerbini et al., 2012 Brazil
Tse et al., 2011 Australia
Cross-sectional. 110 males.
Cross-sectional. 91 males. Cross-sectional. 3623 males. Cross-sectional. 62 males. Cross-sectional 24,695 males.
Cross-sectional. 11,554 males. Cross-sectional. 53 males. Cross-sectional. 88 males. Cross-sectional. 155 males. Cross-sectional. 647 males. Cross-sectional. 37,783 males.
Kaplan et al., 2009 USA
Stemberga et al., 2010 Croatia
Cross-sectional 1151 males.
Darke et al., 2009 Australia
Mukamal et al., 2007 USA
Wirthwein et al., 2002 USA
Nowers, 1999 England
Davis, 1999 USA
Avis, 1993 Canada
Marzuk et al., 1992 USA
Auer, 1990 Finland
Fishbain et al., 1987 USA
Study type
Authors, year and country
Family history of suicide.
Overconsumption of alcohol or drugs.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Suicide by hanging.
Attempted Suicide by drowning. Suicide by gunshot.
Suicide by hanging.
Suicide by gunshot, sharp or blunt instrument, hanging, fall or drowning. Suicide by hanging.
Suicide by drowning.
Suicide by hanging.
Suicide by hanging.
Suicide by drowning.
Suicide by nonoverdose methods (e.g. hanging, jumping, drowning or gunshot). Suicide by gunshot.
Suicide by gunshot.
Suicide by drowning
Suicide by drowning
Suicide by drowning
Suicide by drowning
Suicide by gunshot.
Suicide by drowning
Attempted suicide by gunshot. Attempted suicide by gunshot. Suicide by gunshot.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Suicide by drowning or sharp instrument.
Suicide/suicide attempt method
Overconsumption of alcohol or drugs.
Symptoms
Table 1 Characteristics of the studies identified by the systematic search (listed chronologically).
(continued on next page)
Among those committing suicide, having an alcohol problem was associated with an adjusted odds ratio (AOR) of 1.08 (95%CI=1.01–1.16) for using gunshot as means of suicide. For other substance abuse problems, the AOR was 0.59 (95%CI= 0.53–0.65). 0% had a family history of suicide.
55% had used alcohol within 6 h prior to the suicide attempt.
31% had blood alcohol levels ≥0.2 g/L according to the autopsy report.
62% had alcohol in the blood according to the autopsy report.
25% had blood alcohol concentrations ≥ 0.08 g/L.
24% had blood alcohol levels ≥0.2 g/L according to the autopsy report.
41% had blood alcohol levels >0.2 g/L according to the autopsy report.
39% had alcohol in the blood according to the autopsy report.
42% had alcohol in the blood according to the autopsy report.*
27% had blood alcohol concentration ≥0.08% according to the autopsy report.
For those consuming ≥30 g alcohol (two drinks or more) per drinking day, the hazard ratio for suicide by gunshot was 3.89 (95% CI=0.67–22.60; P-trend 0.02), when adjusted for drinking frequency. 44% had alcohol/drugs in the blood according to the autopsy report.
57% had alcohol/drugs in the blood according to the autopsy report.
17% had alcohol in the blood according to the autopsy report.
43% had alcohol/drugs in the blood according to the autopsy report.
14% had alcohol in the blood according to the autopsy report.
61% had alcohol/drugs in the blood/urine according to the autopsy report.
22% had alcohol/drugs in the blood according to the autopsy report.
29% had alcohol/drugs in body fluids according to the autopsy report.
59% had used alcohol or drugs in relation to the suicide attempt.
67% had used alcohol in relation to the suicide attempt.
67% had alcohol or drugs in their blood at the time of suicide.
Results
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Journal of Affective Disorders 262 (2020) 55–61 ⁎ Blood from 10 of the 134 suicide victims (both male and female) could not be analyzed due to advanced state of decomposition. The sex of these 10 individuals was not provided. Hence, that 42% of males had alcohol in the blood at the time of the suicide is likely a slight underestimate. ⁎⁎ Data was not available for one of the 10 respondents. The studies focusing on suicide attempts are marked with bold text.
41% has blood alcohol concentration ≥0,10 according to the autopsy report. Cross-sectional. 10,965 males. Rockett et al., 2018 USA
Overconsumption of alcohol.
Cross-sectional. 307 males.
Bhatt et al., 2018 Canada
Abbas et al., 2018 Iraq
Paraschakis et al., 2018 Greece
Overconsumption of alcohol or drugs.
23% had drugs or alcohol in the blood in the toxicological exam.
4% was under the effect of alcohol during suicide. 1% had a family history with suicide and 1% had a family history of suicide attempt. 0% answered yes to drinking alcohol during the suicide attempt.⁎⁎
Suicide by drowning, jumping from a height, firearm, hanging or self-burning. Attempted suicide by hanging, drowning, burning, jumping from a height, suffocation or explosion. Suicide by hanging, drowning, firearm, jumping from a height or getting run over by train or car. Suicide by hanging or firearm. Overconsumption of alcohol and family history of suicide. Overconsumption of alcohol.
24% had a substance use disorder. Suicide by firearm or hanging.
Cross-sectional 33 males. Cross-sectional. 353 males. Cross-sectional. 10 males. Abdullah et al., 2018 Pakistan
Overconsumption of alcohol or drugs.
Study type Authors, year and country
Table 1 (continued)
Symptoms
Suicide/suicide attempt method
Results
E.H. Sørensen, et al.
drowning, seven studies reported exclusively on gunshot (all these studies used data from the United States), five studies reported exclusively on hanging, while eight studies reported on more than one violent method (drowning, gunshot, hanging, jumping etc.). The only “symptoms” compatible with the male depressive syndrome, which was reported in the 28 studies included in this review, was intake of alcohol and/or drugs in relation to the violent suicide/ suicide attempt references (item 9 in the GMDS:“Overconsumption of alcohol and pills in order to achieve a calming and relaxing effect” (Zierau et al., 2002)) and family history of suicide/suicide attempt (Abbas et al., 2018; Selvaraj and Sadasivam, 2017) (item 13 in the GMDS: “In your biological family, is there any tendency towards abuse, depression/dejection, suicide attempts or proneness to behavior involving danger?” (Zierau et al., 2002)). Specifically, in 12 of the studies, more than 40% of the suicide/suicide attempt victims had used alcohol or drugs in relation to the incident. Only two of the studies reported on suicide/suicide attempts in the family, namely Selvaraj and Sadasivam (2017), who reported no family history of suicide among 110 males from India who died by hanging themselves, and Abbas et al. (2018), who reported that among 353 Iraqi males dying by suicide via drowning, jumping from heights, firearm, hanging or self-burning, 1% had a family history of suicide and another 1% had a family history of suicide attempt. Notably, none of the 28 studies had systematically assessed for other symptoms of male depression. 4. Discussion With this systematic review we aimed to investigate the association between male depression as operationalized by the Gotland Male Depression Scale (GMDS) and violent suicide/suicide attempts. Our search of the literature identified a total of 28 independent studies published in the period from 1970 to 2018, which reported data on 91,933 violent suicides and 113 violent suicide attempts among males. The only two symptoms from the GMDS that were reported in relation to violent suicides/suicide attempts was overconsumption of alcohol or drugs and prior suicide/suicide attempt in the biological family. The association between (predominantly acute) alcohol/drug consumption and suicide/suicide attempts is well known and was recently – in the case of alcohol – systematically reviewed by Borges et al. (2017) and Borges and Loera (2010). Even though we decided not to expand our search to systematically cover the association between alcohol/drug consumption and violent suicide/suicide attempts, the results from our review shows that this link is indeed present. However, whether this association reflects a more consistent use of psychoactive substances (i.e. a potential sign of male depression as described in the GMDS (Zierau et al., 2002)) or merely represents an acute mean to become sufficiently serene to carry out a suicide/suicide attempt remains unclear. That being said, the results of the review by Borges et al. (2017) and Borges and Loera (2010) combined with those presented in Table 1 of the present study, do suggest that the “overconsumption of alcohol and pills in order to achieve a calming and relaxing effect” observed in male depression (item 9 in the GMDS (Zierau et al., 2002)) may indeed increase the risk of suicide/suicide attempts – including violent ones. In the two studies with data on the prevalence of family history of suicide/suicide attempts, very low numbers were reported (0–1%). Abbas et al. (2018) reported that among 353 Iraqi males dying by suicide via drowning, jumping from heights, firearm, hanging or selfburning, 1% had a family history of suicide and another 1% had a family history of suicide attempt. However, as this data was provided by family members of the deceased individual and given the stigmatization of suicide in Iraq (Abbas et al., 2018), the risk for underreporting seems substantial. The same is likely to have been the case for the study by Selvaraj and Sadasivam (2017), who reported no family history of suicide among 110 males from India who died by hanging themselves – as the information on family history of suicide was also provided by 59
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similarly, the cohort study by Mukamal et al. (2007) is based on 47,654 males, who entered the study by participating in a survey. Survey respondents were subsequently followed up for vital status using a combination of reports from families, postal officials and the National Death Index. When deaths were reported, the death certificates and pathology reports were reviewed to determine the cause of death (including suicide by gunshot, n = 78). This design is sensitive to selection bias as individuals invited to participate in the survey may have decided not to participate due to male depressive traits and/or suicidal ideation. Whether such a bias has affected the results of this review cannot be determined with the data at hand – since information on those not participating in the studies is not available. However, the results of the study by Mukamal et al. (2007) - namely that alcohol consumption is associated with violent suicide - are consistent with those from the other studies in included in the review, so the effect of a potential selection bias seems to be modest. Information bias is also quite likely to have affected the conclusions of this review. Information bias arises as a consequence of measurement error (misclassification). In the context of the present review, misclassification will have occurred if information on other symptoms of male depression than overconsumption of alcohol or drugs and family history of suicide/suicide attempts were actually available, but either not reported or referred to as something else (e.g., major depression). Along with the lack of focus on symptoms of male depression in the context of violent suicides/suicide attempts in the literature identified by this review, misclassification of male depressive symptoms is probably the main reason for the somewhat meager evidence for the link between male depressive symptoms and violent suicides reported here. Third and finally, although the search of PubMed, Embase and PsycINFO (combined with additional searches of references and the grey literature) resulted in a quite broad screening of the literature conducted independently by two independent authors, we cannot exclude that relevant literature has been missed. However, if this has indeed occurred, it is most likely to have happened at random and should therefore not bias the conclusions of this review. The main conclusion of this systematic review is that symptoms of male depression are rarely reported in relation to violent suicides/suicide attempts. The most likely explanation for this finding is that there has been little focus on this association in the field. Future studies should address this knowledge gap as their results may aid in the identification of a group of individuals that are at significantly elevated risk of dying by suicide.
relatives in this study. Hence, the association between family history of suicide/suicide attempts (a trait compatible with male depression according to the GMDS) in relation to violent suicides is best described as unclear, but intuitively probable. We were surprised to find no studies reporting systematically on any of the other symptoms of male depression (e.g. irritability, aggressiveness, lowered stress threshold, low impulse control, restlessness, and acting-out behavior) in relation to violent suicides/suicide attempts in males. The most likely explanation for this finding is not that such an association does not exist – but rather that there has been little focus on it in the field. Future studies should address this void as the results of such studies may aid in the identification of a group of individuals in severe psychological distress that are of elevated risk of dying by suicide. Conducting psychological autopsy studies focusing on male depressive traits would seem to be a logical first step in this regard. The psychological autopsy study by Gonzalez-Castro et al. (2016) shows that this approach is a promising one. Specifically, Gonzales-Castro et al. reported on 182 psychological autopsies following suicides – predominantly by hanging (84%) – and found that“aggressiveness” (37% of the males vs. 20% of the females) was significantly more prevalent among the males. These findings are consistent with aggression – a key symptom of male depressive according to the GMDS – being a risk factor for (violent) suicide. There are some limitations to this review that should be taken into account by the reader. First and foremost, we restricted our focus to violent suicides among males. It could be argued that assessing male depressive traits in relation to suicide in general – and for both males and females – would have been equally interesting. We chose this focus a priori in order to increase the prior probability of finding a sufficient proportion of publications reporting on male depressive traits among the identified records – due to the well-known overrepresentation of males using violent means of suicide. Secondly, reviews of the literature are sensitive to biases, where publication bias, selection bias, and information bias seem to be of particular relevance in the context of the current study. Publication bias occurs if results of a certain nature are more likely not to be published - or more likely to be published. A potential publication bias affecting the present study would have arisen if journal editors/reviewers would be reluctant to endorse/accept papers focusing on the association between male depression and violent suicides. This does not seem entirely unlikely due to the fact that male depression is not a formal diagnosis in the major diagnostic classification systems (American Psychiatric Association, 2013; WHO, 1993). However, due to the fact that data on the behavior of authors, reviewers and editors is generally not available, we cannot determine whether such a bias affects this review. Selection bias can also affect clinical studies included in reviews – and hence the conclusion of such reviews. This occurs if potential study participants of a certain type opt out (or opt in) for a reason that is somehow related to the exposure/outcome of interest. In the context of the present review, such selection bias has probably only affected the conclusions to a very limited extent. This is due to the fact that the deceased individuals in the cross-sectional studies of suicide (24 of the 28 included studies) can obviously not have opted out - nor were there any indications of family members opting out on behalf of their deceased relative. Of the remaining four studies (those on suicide attempts), Kost-Grant (1983) and Peterson et al. (1985) were cross-sectional studies of suicide attempts with no indication of selection bias. Bhatt et al. (2018) invited hospitalized patients with a history of suicide attempt to participate in their study – and only considered individuals with sufficient mental capacity to provide written informed consent. Consequently, since the study sample does not include individuals who were either too ill to provide informed consent or unwilling to participate, a selection bias may have incurred, which could explain why none of those having attempted suicide with a violent method reported drinking alcohol in relation to the attempt – a finding which is inconsistent with the other studies identified by our review. Somewhat
Role of the funding source SDØ is supported by a grant from the Independent Research Fund Denmark. The funder had no influence on the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. CRediT authorship contribution statement Emil Heilmann Sørensen: Conceptualization. Mette Viller Thorgaard: Conceptualization. Søren Dinesen Østergaard: Conceptualization. Declaration of Competing Interest The authors to declare no conflicts of interest. Acknowledgements The authors thank research librarian Helene Sognstrup, The Royal Library, Aarhus. 60
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Supplementary materials
873–880. Moller-Leimkuhler, A.M., 2002. Barriers to help-seeking by men: a review of sociocultural and clinical literature with particular reference to depression. J. Affect Disord. 71, 1–9. Mukamal, K.J., Kawachi, I., Miller, M., Rimm, E.B., 2007. Drinking frequency and quantity and risk of suicide among men. Soc. Psychiatry Psychiatr. Epidemiol. 42, 153–160. Nordentoft, M., 2007. Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups. Dan. Med. Bull. 54, 306–369. Nowers, M.P., 1999. Suicide by drowning in the bath. Med. Sci. Law 39, 349–353. Olfson, M., Wall, M., Wang, S., Crystal, S., Gerhard, T., Blanco, C., 2017. Suicide following deliberate self-harm. Am. J. Psychiatry 174, 765–774. Ostergaard, S.D., 2018. Increasing male preponderance in suicide coinciding with a reduction by half in total suicides in the Danish population should raise awareness of male depression. Am. J. Psychiatry 175, 381–382. Paraschakis, A., Michopoulos, I., Efstathiou, V., Christodoulou, C., Boyokas, I., Douzenis, A., 2018. A comparative analysis of suicides in Greece’s main port city area of Piraeus before (2006-2010) and during (2011-2015) the country’s severe economic crisis. J. Forensic Leg. Med. 56, 5–8. Persett, P.S., Grimholt, T.K., Ekeberg, O., Jacobsen, D., Myhren, H., 2018. Patients admitted to hospital after suicide attempt with violent methods compared to patients with deliberate self-poisoning -a study of background variables, somatic and psychiatric health and suicidal behavior. BMC Psychiatry 18. Peterson, L.G., Peterson, M., O’shanick, G.J., Swann, A., 1985. Self-inflicted gunshot wounds: lethality of method versus intent. Am. J. Psychiatry 142, 228–231. Poma, S.Z., Toniolo, E., Grossi, A., Pizzo, R., Cocchio, S., Baldo, V., 2013. Epidemiology of suicide attempts in a psychiatric setting in Northern Italy. J. Psychopathol. 19, 119–125. Pompili, M., Innamorati, M., Rihmer, Z., Gonda, X., Serafini, G., Akiskal, H., Amore, M., Niolu, C., Sher, L., Tatarelli, R., Perugi, G., Girardi, P., 2012. Cyclothymic-depressiveanxious temperament pattern is related to suicide risk in 346 patients with major mood disorders. J. Affect. Disord. 136, 405–411. POMPILI, M., Rihmer, Z., Innamorati, M., Lester, D., Girardi, P., Tatarelli, R., 2009. Assessment and treatment of suicide risk in bipolar disorders. Expert Rev. Neurother. 9, 109–136. Rihmer, Z., 2007. Suicide risk in mood disorders. Curr. Opin. Psychiatry 20, 17–22. Rihmer, Z., Rutz, W., Pihlgren, H., 1995. Depression and suicide on Gotland. An intensive study of all suicides before and after a depression-training programme for general practitioners. J. Affect. Disord. 35, 147–152. Rockett, I.R.H., Caine, E.D., Connery, H.S., D’onofrio, G., Gunnell, D.J., Miller, T.R., Nolte, K.B., Kaplan, M.S., Kapusta, N.D., Lilly, C.L., Nelson, L.S., Putnam, S.L., Stack, S., Varnik, P., Webster, L.R., Jia, H., 2018. Discerning suicide in drug intoxication deaths: paucity and primacy of suicide notes and psychiatric history. PLoS ONE 13, e0190200. Rutz, W., von Knorring, L., Pihlgren, H., Rihmer, Z., Walinder, J., 1995. Prevention of male suicides: lessons from Gotland study. Lancet 345, 524. Rutz, W., von Knorring, L., Walinder, J., 1992. Long-term effects of an educational program for general practitioners given by the Swedish committee for the prevention and treatment of depression. Acta Psychiatr. Scand. 85, 83–88. Rutz, W., Walinder, J., Eberhard, G., Holmberg, G., von Knorring, A.L., von Knorring, L., Wistedt, B., Aberg-Wistedt, A., 1989. An educational program on depressive disorders for general practitioners on Gotland: background and evaluation. Acta Psychiatr. Scand. 79, 19–26. Selvaraj, T., Sadasivam, S., 2017. Epidemiological profile of suicide by hanging in Madurai. Indian J. Forensic Med. Toxicol. 11, 86–90. Shields, L.B., Hunsaker, D.M., Hunsaker 3RD, J.C., 2007. Schizophrenia and suicide: a 10year review of Kentucky medical examiner cases. J. Forensic Sci. 52, 930–937. Shields, L.B., Hunsaker, D.M., Hunsaker 3RD, J.C., Ward, M.K., 2006. Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases. Am. J. Forensic Med. Pathol. 27, 106–112. Sjoberg, L., Karlsson, B., Atti, A.R., Skoog, I., Fratiglioni, L., Wang, H.X., 2017. Prevalence of depression: comparisons of different depression definitions in population-based samples of older adults. J. Affect. Disord. 221, 123–131. Stemberga, V., Bralic, M., Coklo, M., Cuculic, D., Bosnar, A., 2010. Suicidal drowning in Southwestern Croatia: a 25-year review. Am. J. Forensic Med. Pathol. 31, 52–54. Tormey, W.P., Srinivasan, R., Moore, T., 2013. Biochemical toxicology and suicide in Ireland: a laboratory study. Ir. J. Med. Sci. 182, 277–281. Tse, R., Sims, N., Byard, R.W., 2011. Alcohol ingestion and age of death in hanging suicides. J. Forensic Sci. 56, 922–924. Weissman, M.M., Bland, R.C., Canino, G.J., Greenwald, S., Hwu, H.G., Joyce, P.R., Karam, E.G., Lee, C.K., Lellouch, J., Lepine, J.P., Newman, S.C., Rubio-stipec, M., Wells, J.E., Wickramaratne, P.J., Wittchen, H.U., Yeh, E.K., 1999. Prevalence of suicide ideation and suicide attempts in nine countries. Psychol. Med. 29, 9–17. WHO, 1993. The ICD-10 Classification of Mental and Behavioural Disorders. Wirthwein, D.P., Barnard, J.J., Prahlow, J.A., 2002. Suicide by drowning: a 20-year review. J. Forensic Sci. 47, 131–136. Zerbini, T., Ponce Jde, C., Mayumi Sinagawa, D., Barbosa Cintra, R., Munoz, D.R., Leyton, V., 2012. Blood alcohol levels in suicide by hanging cases in the state of Sao Paulo, Brazil. J. Forensic Leg. Med. 19, 294–296. Zierau, F., Bille, A., Rutz, W., Bech, P., 2002. The Gotland male depression scale: a validity study in patients with alcohol use disorder. Nord. J. Psychiatry 56, 265–271. WHO, 2019a. Suicide data [Online]. Available:http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/[Accessed 9/9 2019]. WHO, 2019b. Male:female suicide ratio [Online]. Available:http://www.who.int/gho/ mental_health/suicide_rates_male_female/en/[Accessed 9/9 2019].
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jad.2019.10.054. References American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders. Abbas, M.J., Alhemiary, N., Razaq, E.A., Naosh, S., Appleby, L., 2018. The Iraqi national study of suicide: report on suicide data in Iraq in 2015 and 2016. J. Affect. Disord. 229, 56–62. Abdullah, M., Khalily, M.T., Ahmad, I., Hallahan, B., 2018. Psychological autopsy review on mental health crises and suicide among youth in Pakistan. Asia-Pac. Psychiatry 10. Ahlm, K., Lindqvist, P., Saveman, B.I., Bjornstig, U., 2015. Suicidal drowning deaths in northern Sweden 1992-2009 - the role of mental disorder and intoxication. J. Forensic Leg. Med. 34, 168–172. Ahlm, K., Saveman, B.I., Bjornstig, U., 2013. Drowning deaths in Sweden with emphasis on the presence of alcohol and drugs - a retrospective study, 1992-2009. BMC Public Health 13, 216. Auer, A., 1990. Suicide by drowning in Uusimaa province in southern Finland. Med. Sci. Law 30, 175–179. Avis, S.P., 1993. Suicidal drowning. J. Forensic Sci. 38, 1422–1426. Ayuso-Mateos, J.L., Vazquez-Barquero, J.L., Dowrick, C., Lehtinen, V., Dalgard, O.S., Casey, P., Wilkinson, C., Lasa, L., Page, H., Dunn, G., Wilkinson, G., 2001. Depressive disorders in Europe: prevalence figures from the Odin study. Br. J. Psychiatry 179, 308–316. Bhatt, M., Perera, S., Zielinski, L., Eisen, R.B., Yeung, S., Elsheikh, W., Dejesus, J., Rangarajan, S., Sholer, H., Iordan, E., Mackie, P., Islam, S., Dehghan, M., Thabane, L., Samaan, Z., 2018. Profile of suicide attempts and risk factors among psychiatric patients: a case-control study. PLoS ONE 13. Bilban, M., Skibin, L., 2005. Presence of alcohol in suicide victims. Forensic Sci. Int. 147 (Suppl), S9–12. Borges, G., Bagge, C.L., Cherpitel, C.J., Conner, K.R., Orozco, R., Rossow, I., 2017. A meta-analysis of acute use of alcohol and the risk of suicide attempt. Psychol. Med. 47, 949–957. Borges, G., Loera, C.R., 2010. Alcohol and drug use in suicidal behaviour. Curr. Opin. Psychiatry 23, 195–204. Choi, N.G., Dinitto, D.M., Marti, C.N., Kaplan, M.S., Conwell, Y., 2017. Suicide means among decedents aged 50+ years, 2005-2014: trends and associations with sociodemographic and precipitating factors. Am. J. Geriatr. Psychiatry 25, 1404–1414. Darke, S., Duflou, J., Torok, M., 2009. Toxicology and circumstances of completed suicide by means other than overdose. J. Forensic Sci. 54, 490–494. Davis, L.G., 1999. Suicidal drowning in south Florida. J. Forensic Sci. 44, 902–905. Fishbain, D.A., Fletcher, J.R., Aldrich, T.E., Davis, J.H., 1987. Relationship between Russian roulette deaths and risk-taking behavior: a controlled study. Am. J. Psychiatry 144, 563–567. Geertinger, P., Voigt, J., 1970. Death in the bath. A survey of bathtub deaths in Copenhagen, Denmark, and Gothenburg, Sweden, from 1961 to 1969. J. Forensic Med. 17, 136–147. Giner, L., Jaussent, I., Olie, E., Beziat, S., Guillaume, S., Baca-Garcia, E., LopezCastroman, J., Courtet, P., 2014. Violent and serious suicide attempters: one step closer to suicide? J. Clin. Psychiatry 75, e191–e197. Gonzalez-Castro, T.B., Hernandez-Diaz, Y., Tovilla-Zarate, C.A., Gonzalez-Gutierrez, K.P., Fresan, A., Juarez-Rojop, I.E., Lopez-Narvaez, L., Villar Soto, M., Genis, A., 2016. Differences by gender in completed suicides in a Mexican population: a psychological autopsy study. J. Forensic Leg. Med. 38, 70–74. Hartley, D.P., Petersen, D.R., 1993. Metabolic interactions of 4-hydroxynonenal, acetaldehyde and glutathione in isolated liver mitochondria. Adv. Exp. Med. Biol. 328, 27–36. Haw, C., Hawton, K., 2016. Suicide and self-harm by drowning: a review of the literature. Arch. Suicide Res. 20, 95–112. Henriksson, M.M., Aro, H.M., Marttunen, M.J., Heikkinen, M.E., Isometsa, E.T., kuoppasalmi, K.I., Lonnqvist, J.K., 1993. Mental disorders and comorbidity in suicide. Am. J. Psychiatry 150, 935–940. Innamorati, M., Pompili, M., Gonda, X., Amore, M., Serafini, G., Niolu, C., Lester, D., Rutz, W., Rihmer, Z., Girardi, P., 2011. Psychometric properties of the Gotland scale for depression in Italian psychiatric inpatients and its utility in the prediction of suicide risk. J. Affect. Disord. 132, 99–103. Jones, A.W., Holmgren, A., Ahlner, J., 2013. Toxicology findings in suicides: concentrations of ethanol and other drugs in femoral blood in victims of hanging and poisoning in relation to age and gender of the deceased. J. Forensic Leg. Med. 20, 842–847. Kaplan, M.S., Mcfarland, B.H., Huguet, N., 2009. Characteristics of adult male and female firearm suicide decedents: findings from the national violent death reporting system. Inj. Prev. 15, 322–327. Kaplan, M.S., Mcfarland, B.H., Huguet, N., Conner, K., Caetano, R., Giesbrecht, N., Nolte, K.B., 2013. 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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Review article
Male depressive traits in relation to violent suicides or suicide attempts: A systematic review Emil Heilmann Sørensena,b, Mette Viller Thorgaardb,c, Søren Dinesen Østergaardb,c,
T
⁎
a
Horsens Regional Hospital, Horsens, Denmark Department of Clinical Medicine, Aarhus University, Aarhus, Denmark c Department of Affective Disorders, Aarhus University Hospital, Aarhus, Denmark b
A B S T R A C T
Background: : Male sex is a consistently reported risk factor for violent suicide. It has been suggested that this association may be driven by so-called male depression - as operationalized by the Gotland Male Depression Scale (GMDS). The aim of this systematic review was to investigate if males dying by or attempting suicide with violent methods, display symptoms compatible with male depression. Methods: : This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search of PubMed, Embase and PsycINFO was performed using search terms covering: male sex, violent suicide/suicide attempt, and symptoms of male depression from the GMDS. Subsequently, a qualitative synthesis of studies meeting predefined inclusion criteria was carried out. Results: : A total of 28 studies reporting on 91,933 violent suicides and 113 violent suicide attempts were included in the qualitative synthesis. The suicide/suicide attempt methods reported in these studies were predominantly shooting, hanging or drowning. The only two symptoms from the GMDS that was reported in relation to violent suicides/suicide attempts was overconsumption of alcohol or drugs and suicide attempts in the biological family. No studies had systematically assessed suicide victims or attempters for symptoms of male depression. Limitations: : Publication-, selection-, and information biases may have affected this review. Conclusions: : Symptoms of male depression are rarely reported in relation to violent suicides/suicide attempts. The most likely explanation for this finding is that there has been little focus on this potential association. Future studies should address this void.
1. Introduction Suicide is responsible for approximately 800,000 deaths worldwide every year according to the World Health Organization and is now the second leading cause of death among the 15–29 year old (WHO, 2019a). Mental disorders – and major depression in particular – are strong risk factors for suicide, with nearly two thirds of people dying by suicide suffering from a depressive disorder (Henriksson et al., 1993; WHO, 1993). Although there is a strong association between mood disorder and suicide, the majority of individuals with a mood disorder does not die by suicide (Pompili et al., 2009; Rihmer, 2007), and identifying those at high risk of suicide is therefore instrumental to allow for effective prevention (Olfson et al., 2017; Nordentoft, 2007). Another consistently reported risk factor for suicide is male sex. Specifically, the global male-to-female ratio of age-standardized suicide rate was 1.8 in 2016 (WHO, 2019b). This is somewhat paradoxical given that major depression is approximately twice as prevalent among females (Ayuso-Mateos et al., 2001; Sjoberg et al., 2017) and that suicide attempts are also much more common among females compared to males (Poma et al., 2013; Weissman et al., 1999). There are probably
⁎
several (potentially interacting) explanations for this apparent paradox. First, males are less likely to seek help when in psychological distress (Hartley and Petersen, 1993; Moller-Leimkuhler, 2002). Second, when males attempt suicide they use more violent methods than females (Persett et al., 2018; Bilban and Skibin, 2005) such as hanging, use of a firearm or jumping from heights (Rihmer et al., 1995; Giner et al., 2014), and alcohol is often involved (Bilban and Skibin, 2005). Third, it has been suggested that the prevalence of depression among males is probably equivalent to that among females, but that depression in males typically manifests in a different manner (Rutz et al., 1995). Therefore, this alleged “male depression” does often not meet the criteria for major depression (Zierau et al., 2002) as operationalized in the major diagnostic guidelines (American Psychiatric Association, 2013) and consequently often goes undetected and untreated - which may ultimately lead to suicide (Rutz et al., 1995). A recent study supporting this hypothesis is that by Ostergaard, which demonstrated that the male-female suicide ratio in Denmark has increased quite dramatically over the past three decades (from 1.75 to approximately 2.75) during which the absolute number of suicides was approximately halved (Ostergaard, 2018). These coinciding developments are compatible
Corresponding author at: Department of Affective Disorders, Aarhus University Hospital, Palle Juul Jensens Boulevard 175, 8200 Aarhus N. E-mail address: [email protected] (S.D. Østergaard).
https://doi.org/10.1016/j.jad.2019.10.054 Received 13 August 2019; Received in revised form 9 September 2019; Accepted 28 October 2019 Available online 30 October 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
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with the existence of male depression - since the drop in the total number of suicides during this period of time is at least partly driven by improved care and treatment of major depression, whereas the male depressions are more likely to have gone undetected and untreated (Ostergaard, 2018). The male depression concept stems from the so-called Gotland study in which general practitioners on the Swedish island of Gotland received education in diagnosing and treating major depression (Rutz et al., 1992; Rutz et al., 1989). This education program led to significantly increased use of antidepressants, while the rate of hospital admissions for depression and suicides was reduced (Rutz et al., 1992; Rutz et al., 1989). In a follow-up analysis it was demonstrated that the reduced suicide rate on Gotland was driven entirely by reductions in female suicides, while the rate of male suicide remained virtually unaffected (Rutz et al., 1995). This observation led Rutz et al. to propose the existence of a particular type of depression (Rutz et al., 1995) that mainly affected males, and which they later operationalized in the Gotland Male Depression Scale (GMDS) (Zierau et al., 2002). According to the GMDS (see Appendix 1 in the supplementary material), the symptom definition of male depression differs from that of classical major depression, by also considering symptoms such as irritability, aggressiveness, lowered stress threshold, low impulse control, restlessness, substance abuse, acting-out behavior and family history of suicide attempts/proneness to dangerous behavior (Zierau et al., 2002). Prior studies have suggested that male depression (higher scores on the GMDS) are linked to suicide proneness among psychiatric inpatients (Innamorati et al., 2011; Pompili et al., 2012). When considering i) the symptoms defining male depression (irritability, aggressiveness, lowered stress threshold, low impulse control, restlessness, substance abuse, and acting-out behavior) (Zierau et al., 2002), ii) the proposed link between male depression and suicide proneness (Innamorati et al., 2011; Pompili et al., 2012), and iii) the fact that males tend to use violent means when attempting suicide (Persett et al., 2018; Bilban and Skibin, 2005), it seems quite likely that male depression is linked to violent suicides/suicide attempts. Therefore, the aim of this systematic review was to determine whether symptoms compatible with male depression are prevalently reported for males who die by violent suicides or attempt suicide with a violent method. If this is the case, it emphasizes the need to take the male depression phenotype seriously. If not, it is most likely a consequence of there having been little focus on this association in the field – and calls for further studies on this specific topic.
"Behavioral Symptoms"[Title/Abstract] OR "Aggression"[Title/Abstract] OR male depressi*[Title/Abstract] OR "acting out"[Title/Abstract] OR substance related disorder*[Title/Abstract])))) AND ("Suicide"[Mesh] OR suicid*)) AND ("Men"[Mesh] OR men OR male)) Filters: English”. Equivalent searches of Embase and PsycINFO were conducted (see the search strings in the supplementary material).
2. Methods
2.3. Post hoc decision regarding alcohol and drug use in relation to violent suicide/suicide attempts
2.2. Inclusion criteria Studies were included in the qualitative synthesis if meeting all of the following criteria: 1 Containing original data on completed suicides or suicide attempts using violent methods (e.g. shooting, hanging, jumping from heights and/or drowning). 2 Containing data on males (in case of studies that included data on females, specific data on males was required for inclusion). 3 Covering symptoms compatible with the male depressive syndrome (that are not part of the major depressive syndrome) as operationalized by the GMDS. 4 Using English language and published in a journal with peer review (the latter to ensure sufficient quality of the reported data). Single case studies and systematic reviews were not included. The screening and selection of literature was conducted independently by EHS and MVT. Initially, the identified records were screened for eligibility based on title and abstract. When title and abstract indicated that a record could be eligible for inclusion, the full-text version of the article was retrieved and evaluated. If the full-text version of the article indicated that the study had led to results that were eligible for inclusion, but that these results were not included in the article, an e-mail was sent to the author, asking for access to the results in question. These results were then reviewed for eligibility. The references of included articles were independently screened for further relevant records by EHS and MVT. Any disagreement regarding eligibility was initially discussed between EHS and MVT. If an agreement was not reached, SDØ was consulted and a final decision regarding inclusion was made. The following information was extracted from all included articles: publication year, setting (country), study design, sample size (number of violent suicides/suicide attempts), reported symptoms of male depression, (attempted) suicide method, and main results (focusing on symptoms compatible with the male depressive syndrome).
2.1. Search string During our screening of the literature, we discovered that while the search appeared to have systematic coverage for the symptoms of male depression in general, there was one exception to this rule. Specifically, we found that the search did not cover all studies of violent suicides/ suicide attempts in relation to which the victim had ingested alcohol or drugs. Since there is a quite large body of literature on the association between consumption of psychoactive substances and suicide in general (Borges et al., 2017; Borges and Loera, 2010), covering this aspect in the context of male depression seems somewhat futile. Also, consumption of alcohol and pills in relation to suicides/suicide attempts can rightfully be regarded as an acute means to become sufficiently serene to carry out the act (Borges et al., 2017; Borges and Loera, 2010) – rather than an underlying symptom of male depression. For these reasons, we decided that we would i) not expand the search to fully cover the literature on the intake of alcohol/pills/drugs of abuse in relation to violent suicides/suicide attempts, ii) report the results on this association as identified via our original search strategy, and iii) that the qualitative synthesis of our review would have relatively little emphasis on this association, which is already well established. Rather, we decided to focus on the other symptoms of male depression in
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline (Moher et al., 2009). The databases PubMed, Embase and PsycINFO were systematically searched for relevant literature on February 5th, 2019. The search string used for PubMed was as follows: “(((("Firearms"[Mesh] OR "Wounds, Gunshot"[Mesh] OR "Drowning"[Mesh])) OR ((firearm*[Title/Abstract] OR Gunshot[Title/Abstract] OR gun[Title/Abstract] OR guns[Title/Abstract] OR shoots [Title/Abstract] OR shooting[Title/Abstract] OR drown*[Title/Abstract] OR hang*[Title/Abstract] OR jump*[Title/Abstract] OR violent suicide*)))) AND (((((("Frustration"[Mesh] OR "Irritable Mood"[Mesh] OR "Burnout, Professional"[Mesh] OR "Affective Symptoms"[Mesh] OR "Behavioral Symptoms"[Mesh:noexp] OR "Aggression"[Mesh:noexp] OR "Acting Out"[Mesh] OR "Substance-Related Disorders"[Mesh] OR "Lethargy"[Mesh])) OR (("frustration"[Title/Abstract] OR "self-pity"[Title/ Abstract] OR "indecision"[Title/Abstract] OR "emptiness"[Title/Abstract] OR "Irritable Mood"[Title/Abstract] OR "irritability"[Title/Abstract] OR "lethargy"[Title/Abstract] OR "burnout"[Title/Abstract] OR "burn out"[Title/Abstract] OR "Affective Symptoms"[Title/Abstract] OR 56
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Idenficaon
PubMed n = 279
Embase n = 217
PsycINFO n = 153
Records idenfied through database searches n = 649 Duplicates removed n = 86
Screening
Records screened via tle and abstract n = 563
Records excluded if inclusion criteria were not fulfilled n = 344
Included
Eligibility
Full-text arcles reviewed for eligibility n = 219 Full-text arcles excluded if inclusion criteria were not fulfilled n = 199
Screening of references of included arcles and the grey literature
Arcles included via inial screening n = 20
Arcles included via screening n=8
Arcles included in qualitave synthesis n = 28
Fig. 1. Flowchart illustrating the screening and selection of literature.
whether results meeting the eligibility criteria were available. The authors of these 49 studies were contacted and upon review of the response/data sent by these authors (or lack of response), further 45 studies were excluded. The remaining 20 articles were included in the review. The references from the 20 included articles were screened for eligibility, resulting in inclusion of another eight articles. The screening of the grey literature did not result in further inclusion. Hence, a total of 28 articles were included in the qualitative synthesis. The characteristics of the 28 included studies are outlined in Table 1. The studies were published in the period from 1970 to 2018 and reported data on 92,046 males from 14 countries (11 studies with data from the United States). Apart from two studies, namely the cohort study by Mukamal et al. (2007) and the case control study by Bhatt et al. (2018), all studies were cross-sectional and the vast majority of those were based on data from autopsies. There were 24 studies on completed violent suicide (n = 91,933) and four on violent suicide attempts (n = 113). In terms of the violent suicide/suicide attempt methods, eight of the studies reported data exclusively regarding
relation to violent suicides/suicide, where the association is less/not established. 3. Results The literature screening process is illustrated in Fig. 1. A total of 649 records were identified in PubMed, Embase and PsycINFO. After removal of duplicates (n = 86) using Endnote, the 563 remaining records were initially screened based on title and abstract following which 344 records were excluded because they did not meet the inclusion criteria. Full-text versions of the remaining 219 records were retrieved and screened for eligibility. Of these, 154 articles were excluded, either because they did not meet the inclusion criteria (n=152), or if the data in the articles had already been included via other articles (n = 2). The latter was the case for the data presented in Ahlm et al. (2015) and in Shields et al. (2007) al. (Ahlm et al., 2015) Shields et al., 2007), which was included via the larger studies by the same research groups (Ahlm et al., 2013; Shields et al., 2006). For 49 articles, it was unclear 57
Cross-sectional. 9 males. Cross-sectional. 24 males.
Cross-sectional. 17 males. Cross-sectional. 95 males. Cross-sectional. 27 males. Cross-sectional.54 males. Cross-sectional. 14 males. Cross-sectional. 14 males. Cross-sectional. 6 males. Cross-sectional. 28 males. Cohort study. 78 males.
Geertinger and Voigt, 1970 Denmark and Sweden Kost-Grant, 1983 USA
Peterson et al., 1985 USA
58
Selvaraj and Sadasivam, 2017 India
Choi et al., 2017 USA
Haw and Hawton, 2016 England
Jones et al., 2013 Sweden
Tormey et al., 2013 Ireland
Kaplan et al., 2013 USA
Ahlm et al., 2013 Sweden
Zerbini et al., 2012 Brazil
Tse et al., 2011 Australia
Cross-sectional. 110 males.
Cross-sectional. 91 males. Cross-sectional. 3623 males. Cross-sectional. 62 males. Cross-sectional 24,695 males.
Cross-sectional. 11,554 males. Cross-sectional. 53 males. Cross-sectional. 88 males. Cross-sectional. 155 males. Cross-sectional. 647 males. Cross-sectional. 37,783 males.
Kaplan et al., 2009 USA
Stemberga et al., 2010 Croatia
Cross-sectional 1151 males.
Darke et al., 2009 Australia
Mukamal et al., 2007 USA
Wirthwein et al., 2002 USA
Nowers, 1999 England
Davis, 1999 USA
Avis, 1993 Canada
Marzuk et al., 1992 USA
Auer, 1990 Finland
Fishbain et al., 1987 USA
Study type
Authors, year and country
Family history of suicide.
Overconsumption of alcohol or drugs.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Suicide by hanging.
Attempted Suicide by drowning. Suicide by gunshot.
Suicide by hanging.
Suicide by gunshot, sharp or blunt instrument, hanging, fall or drowning. Suicide by hanging.
Suicide by drowning.
Suicide by hanging.
Suicide by hanging.
Suicide by drowning.
Suicide by nonoverdose methods (e.g. hanging, jumping, drowning or gunshot). Suicide by gunshot.
Suicide by gunshot.
Suicide by drowning
Suicide by drowning
Suicide by drowning
Suicide by drowning
Suicide by gunshot.
Suicide by drowning
Attempted suicide by gunshot. Attempted suicide by gunshot. Suicide by gunshot.
Overconsumption of alcohol.
Overconsumption of alcohol or drugs.
Suicide by drowning or sharp instrument.
Suicide/suicide attempt method
Overconsumption of alcohol or drugs.
Symptoms
Table 1 Characteristics of the studies identified by the systematic search (listed chronologically).
(continued on next page)
Among those committing suicide, having an alcohol problem was associated with an adjusted odds ratio (AOR) of 1.08 (95%CI=1.01–1.16) for using gunshot as means of suicide. For other substance abuse problems, the AOR was 0.59 (95%CI= 0.53–0.65). 0% had a family history of suicide.
55% had used alcohol within 6 h prior to the suicide attempt.
31% had blood alcohol levels ≥0.2 g/L according to the autopsy report.
62% had alcohol in the blood according to the autopsy report.
25% had blood alcohol concentrations ≥ 0.08 g/L.
24% had blood alcohol levels ≥0.2 g/L according to the autopsy report.
41% had blood alcohol levels >0.2 g/L according to the autopsy report.
39% had alcohol in the blood according to the autopsy report.
42% had alcohol in the blood according to the autopsy report.*
27% had blood alcohol concentration ≥0.08% according to the autopsy report.
For those consuming ≥30 g alcohol (two drinks or more) per drinking day, the hazard ratio for suicide by gunshot was 3.89 (95% CI=0.67–22.60; P-trend 0.02), when adjusted for drinking frequency. 44% had alcohol/drugs in the blood according to the autopsy report.
57% had alcohol/drugs in the blood according to the autopsy report.
17% had alcohol in the blood according to the autopsy report.
43% had alcohol/drugs in the blood according to the autopsy report.
14% had alcohol in the blood according to the autopsy report.
61% had alcohol/drugs in the blood/urine according to the autopsy report.
22% had alcohol/drugs in the blood according to the autopsy report.
29% had alcohol/drugs in body fluids according to the autopsy report.
59% had used alcohol or drugs in relation to the suicide attempt.
67% had used alcohol in relation to the suicide attempt.
67% had alcohol or drugs in their blood at the time of suicide.
Results
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Journal of Affective Disorders 262 (2020) 55–61 ⁎ Blood from 10 of the 134 suicide victims (both male and female) could not be analyzed due to advanced state of decomposition. The sex of these 10 individuals was not provided. Hence, that 42% of males had alcohol in the blood at the time of the suicide is likely a slight underestimate. ⁎⁎ Data was not available for one of the 10 respondents. The studies focusing on suicide attempts are marked with bold text.
41% has blood alcohol concentration ≥0,10 according to the autopsy report. Cross-sectional. 10,965 males. Rockett et al., 2018 USA
Overconsumption of alcohol.
Cross-sectional. 307 males.
Bhatt et al., 2018 Canada
Abbas et al., 2018 Iraq
Paraschakis et al., 2018 Greece
Overconsumption of alcohol or drugs.
23% had drugs or alcohol in the blood in the toxicological exam.
4% was under the effect of alcohol during suicide. 1% had a family history with suicide and 1% had a family history of suicide attempt. 0% answered yes to drinking alcohol during the suicide attempt.⁎⁎
Suicide by drowning, jumping from a height, firearm, hanging or self-burning. Attempted suicide by hanging, drowning, burning, jumping from a height, suffocation or explosion. Suicide by hanging, drowning, firearm, jumping from a height or getting run over by train or car. Suicide by hanging or firearm. Overconsumption of alcohol and family history of suicide. Overconsumption of alcohol.
24% had a substance use disorder. Suicide by firearm or hanging.
Cross-sectional 33 males. Cross-sectional. 353 males. Cross-sectional. 10 males. Abdullah et al., 2018 Pakistan
Overconsumption of alcohol or drugs.
Study type Authors, year and country
Table 1 (continued)
Symptoms
Suicide/suicide attempt method
Results
E.H. Sørensen, et al.
drowning, seven studies reported exclusively on gunshot (all these studies used data from the United States), five studies reported exclusively on hanging, while eight studies reported on more than one violent method (drowning, gunshot, hanging, jumping etc.). The only “symptoms” compatible with the male depressive syndrome, which was reported in the 28 studies included in this review, was intake of alcohol and/or drugs in relation to the violent suicide/ suicide attempt references (item 9 in the GMDS:“Overconsumption of alcohol and pills in order to achieve a calming and relaxing effect” (Zierau et al., 2002)) and family history of suicide/suicide attempt (Abbas et al., 2018; Selvaraj and Sadasivam, 2017) (item 13 in the GMDS: “In your biological family, is there any tendency towards abuse, depression/dejection, suicide attempts or proneness to behavior involving danger?” (Zierau et al., 2002)). Specifically, in 12 of the studies, more than 40% of the suicide/suicide attempt victims had used alcohol or drugs in relation to the incident. Only two of the studies reported on suicide/suicide attempts in the family, namely Selvaraj and Sadasivam (2017), who reported no family history of suicide among 110 males from India who died by hanging themselves, and Abbas et al. (2018), who reported that among 353 Iraqi males dying by suicide via drowning, jumping from heights, firearm, hanging or self-burning, 1% had a family history of suicide and another 1% had a family history of suicide attempt. Notably, none of the 28 studies had systematically assessed for other symptoms of male depression. 4. Discussion With this systematic review we aimed to investigate the association between male depression as operationalized by the Gotland Male Depression Scale (GMDS) and violent suicide/suicide attempts. Our search of the literature identified a total of 28 independent studies published in the period from 1970 to 2018, which reported data on 91,933 violent suicides and 113 violent suicide attempts among males. The only two symptoms from the GMDS that were reported in relation to violent suicides/suicide attempts was overconsumption of alcohol or drugs and prior suicide/suicide attempt in the biological family. The association between (predominantly acute) alcohol/drug consumption and suicide/suicide attempts is well known and was recently – in the case of alcohol – systematically reviewed by Borges et al. (2017) and Borges and Loera (2010). Even though we decided not to expand our search to systematically cover the association between alcohol/drug consumption and violent suicide/suicide attempts, the results from our review shows that this link is indeed present. However, whether this association reflects a more consistent use of psychoactive substances (i.e. a potential sign of male depression as described in the GMDS (Zierau et al., 2002)) or merely represents an acute mean to become sufficiently serene to carry out a suicide/suicide attempt remains unclear. That being said, the results of the review by Borges et al. (2017) and Borges and Loera (2010) combined with those presented in Table 1 of the present study, do suggest that the “overconsumption of alcohol and pills in order to achieve a calming and relaxing effect” observed in male depression (item 9 in the GMDS (Zierau et al., 2002)) may indeed increase the risk of suicide/suicide attempts – including violent ones. In the two studies with data on the prevalence of family history of suicide/suicide attempts, very low numbers were reported (0–1%). Abbas et al. (2018) reported that among 353 Iraqi males dying by suicide via drowning, jumping from heights, firearm, hanging or selfburning, 1% had a family history of suicide and another 1% had a family history of suicide attempt. However, as this data was provided by family members of the deceased individual and given the stigmatization of suicide in Iraq (Abbas et al., 2018), the risk for underreporting seems substantial. The same is likely to have been the case for the study by Selvaraj and Sadasivam (2017), who reported no family history of suicide among 110 males from India who died by hanging themselves – as the information on family history of suicide was also provided by 59
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similarly, the cohort study by Mukamal et al. (2007) is based on 47,654 males, who entered the study by participating in a survey. Survey respondents were subsequently followed up for vital status using a combination of reports from families, postal officials and the National Death Index. When deaths were reported, the death certificates and pathology reports were reviewed to determine the cause of death (including suicide by gunshot, n = 78). This design is sensitive to selection bias as individuals invited to participate in the survey may have decided not to participate due to male depressive traits and/or suicidal ideation. Whether such a bias has affected the results of this review cannot be determined with the data at hand – since information on those not participating in the studies is not available. However, the results of the study by Mukamal et al. (2007) - namely that alcohol consumption is associated with violent suicide - are consistent with those from the other studies in included in the review, so the effect of a potential selection bias seems to be modest. Information bias is also quite likely to have affected the conclusions of this review. Information bias arises as a consequence of measurement error (misclassification). In the context of the present review, misclassification will have occurred if information on other symptoms of male depression than overconsumption of alcohol or drugs and family history of suicide/suicide attempts were actually available, but either not reported or referred to as something else (e.g., major depression). Along with the lack of focus on symptoms of male depression in the context of violent suicides/suicide attempts in the literature identified by this review, misclassification of male depressive symptoms is probably the main reason for the somewhat meager evidence for the link between male depressive symptoms and violent suicides reported here. Third and finally, although the search of PubMed, Embase and PsycINFO (combined with additional searches of references and the grey literature) resulted in a quite broad screening of the literature conducted independently by two independent authors, we cannot exclude that relevant literature has been missed. However, if this has indeed occurred, it is most likely to have happened at random and should therefore not bias the conclusions of this review. The main conclusion of this systematic review is that symptoms of male depression are rarely reported in relation to violent suicides/suicide attempts. The most likely explanation for this finding is that there has been little focus on this association in the field. Future studies should address this knowledge gap as their results may aid in the identification of a group of individuals that are at significantly elevated risk of dying by suicide.
relatives in this study. Hence, the association between family history of suicide/suicide attempts (a trait compatible with male depression according to the GMDS) in relation to violent suicides is best described as unclear, but intuitively probable. We were surprised to find no studies reporting systematically on any of the other symptoms of male depression (e.g. irritability, aggressiveness, lowered stress threshold, low impulse control, restlessness, and acting-out behavior) in relation to violent suicides/suicide attempts in males. The most likely explanation for this finding is not that such an association does not exist – but rather that there has been little focus on it in the field. Future studies should address this void as the results of such studies may aid in the identification of a group of individuals in severe psychological distress that are of elevated risk of dying by suicide. Conducting psychological autopsy studies focusing on male depressive traits would seem to be a logical first step in this regard. The psychological autopsy study by Gonzalez-Castro et al. (2016) shows that this approach is a promising one. Specifically, Gonzales-Castro et al. reported on 182 psychological autopsies following suicides – predominantly by hanging (84%) – and found that“aggressiveness” (37% of the males vs. 20% of the females) was significantly more prevalent among the males. These findings are consistent with aggression – a key symptom of male depressive according to the GMDS – being a risk factor for (violent) suicide. There are some limitations to this review that should be taken into account by the reader. First and foremost, we restricted our focus to violent suicides among males. It could be argued that assessing male depressive traits in relation to suicide in general – and for both males and females – would have been equally interesting. We chose this focus a priori in order to increase the prior probability of finding a sufficient proportion of publications reporting on male depressive traits among the identified records – due to the well-known overrepresentation of males using violent means of suicide. Secondly, reviews of the literature are sensitive to biases, where publication bias, selection bias, and information bias seem to be of particular relevance in the context of the current study. Publication bias occurs if results of a certain nature are more likely not to be published - or more likely to be published. A potential publication bias affecting the present study would have arisen if journal editors/reviewers would be reluctant to endorse/accept papers focusing on the association between male depression and violent suicides. This does not seem entirely unlikely due to the fact that male depression is not a formal diagnosis in the major diagnostic classification systems (American Psychiatric Association, 2013; WHO, 1993). However, due to the fact that data on the behavior of authors, reviewers and editors is generally not available, we cannot determine whether such a bias affects this review. Selection bias can also affect clinical studies included in reviews – and hence the conclusion of such reviews. This occurs if potential study participants of a certain type opt out (or opt in) for a reason that is somehow related to the exposure/outcome of interest. In the context of the present review, such selection bias has probably only affected the conclusions to a very limited extent. This is due to the fact that the deceased individuals in the cross-sectional studies of suicide (24 of the 28 included studies) can obviously not have opted out - nor were there any indications of family members opting out on behalf of their deceased relative. Of the remaining four studies (those on suicide attempts), Kost-Grant (1983) and Peterson et al. (1985) were cross-sectional studies of suicide attempts with no indication of selection bias. Bhatt et al. (2018) invited hospitalized patients with a history of suicide attempt to participate in their study – and only considered individuals with sufficient mental capacity to provide written informed consent. Consequently, since the study sample does not include individuals who were either too ill to provide informed consent or unwilling to participate, a selection bias may have incurred, which could explain why none of those having attempted suicide with a violent method reported drinking alcohol in relation to the attempt – a finding which is inconsistent with the other studies identified by our review. Somewhat
Role of the funding source SDØ is supported by a grant from the Independent Research Fund Denmark. The funder had no influence on the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. CRediT authorship contribution statement Emil Heilmann Sørensen: Conceptualization. Mette Viller Thorgaard: Conceptualization. Søren Dinesen Østergaard: Conceptualization. Declaration of Competing Interest The authors to declare no conflicts of interest. Acknowledgements The authors thank research librarian Helene Sognstrup, The Royal Library, Aarhus. 60
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Supplementary materials
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