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START study in New Caledonia: A psychological autopsy case series
Journal of Affective Disorders xxx (xxxx) xxx–xxx
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Research paper
The WHO/START study in New Caledonia: A psychological autopsy case series ⁎
Benjamin Goodfellowa,b, , Kairi Kõlvesa, Anne-Cécile Selefenc, Tiffany Massainb, Stéphane Amadéod, Diego De Leoa a Australian Institute of Suicide Research and Prevention, World Health Organization Collaborating Centre for Research in Suicide Prevention and Training, Griffith University, Mt Gravatt, Australia b Centre Hospitalier Albert Bousquet, Nouméa, New Caledonia c Direction de la Sécurité Publique de la Nouvelle-Calédonie, Nouméa, New Caledonia d Departement of Psychiatry, Centre Hospitalier de Polynésie Française, Association SOS Suicide, French Polynesia
A R T I C LE I N FO
A B S T R A C T
Keywords: Suicide Psychological autopsy Pacific Islands Cultural factors
Background: Limited information is available about suicidal behavior in the Pacific Islands. Forty percent of the New Caledonian population is indigenous Kanak; insights into the characteristics of suicide deaths in this population compared to other ethnic groups would be valuable. The aim of this paper is to deepen our understanding of the cultural underpinnings of suicide in New Caledonia by presenting the results of the WHO/START psychological autopsy study. Method: A case-series psychological autopsy study was conducted based on medical, police files, and interviews with relatives of 52 individuals who died by suicide in 2014 and 2015 in New Caledonia. Results: Kanak indigenous individuals represented more than half of suicides. Prevalence of mental disorders was identified in 62% of suicide decedents; a previous suicide attempt was frequent (37% of cases). A serious argument with a partner was the most prevalent life event (60%). Few warning signs were present among young people and Kanak in general. Conclusion: Comparison with information on the general population suggests indigenous Kanak are more vulnerable and that having a mental health disorder plays an important role in suicide. Violent arguments with a partner could also be a major risk factor. Traditional protective factors (being employed, living with their family or partner, religion) appeared to have limited effect on suicide. Mental health promotion, prevention, and care should be prioritized. Prevention strategies, including domestic violence prevention are recommended in New Caledonia. Further research is needed to better identify young and Kanak subjects at risk of suicide.
1. Introduction New Caledonia has been the scene of struggle between old tribes for land for nearly three thousand years, and since the European colonization in the 19th century, struggles and rebellions by the indigenous Kanak people have never ceased. However, this tropical island paradise on the edge of the Coral Sea has also been a land of peaceful coexistence between different ethnic groups since the Noumea Treaty in 1998. On the one hand, the treaty acknowledges the cultural identity and privileged access to land for the Kanak indigenous people in New Caledonia, and on the other, the possibility for this French overseas territory to become independent after a process of referendums. The different people who coexist in New Caledonia now appear to share one burden,
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that of unnecessary premature death, including suicide. New Caledonia is a tropical archipelago located in the Western Pacific, about 1000 km north of Australia and New Zealand. It was first colonized by Austronesian settlers approximately 1000 BCE. European colonization began in the 19th century. Currently, New Caledonia's population is close to 300,000, mainly indigenous Kanak (40%) and people of European, Polynesian and Asian descent. Suicide rates in New Caledonia have been relatively stable, close to 15 per 100,000 since 1991, when suicide mortality started to be officially recorded by the local health authorities (Fig. 1). This rate is higher than the global 10.5 suicide rate in 2016 (WHO, 2018) and than the 12.1 rate in metropolitan France (WHO, 2018). At close to 3 to 1, the male to female ratio resembles that in the majority of Western countries, however,
Corresponding author at: Centre Hospitalier Albert Bousquet, Nouméa, New Caledonia E-mail address: [email protected] (B. Goodfellow).
https://doi.org/10.1016/j.jad.2019.11.020 Received 26 May 2019; Received in revised form 4 September 2019; Accepted 8 November 2019 Available online 09 November 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
Please cite this article as: Benjamin Goodfellow, et al., Journal of Affective Disorders, https://doi.org/10.1016/j.jad.2019.11.020
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Fig. 1. Age-standardized suicide rates in New Caledonia (1991–2017, per 100,000, medical death certificates, WHO world standard population). Source: Direction des Affaires Sanitaires et Sociales, Nouvelle-Calédonie.
interview lasted between 2 and 4 h and was conducted face to face by a trained interviewer. Conflicting information between informants was resolved by renewed phone calls with all the informants. The relatives of 52 suicide victims agreed to take part in the study, giving a participation rate of 69.3%. Interviews were conducted on average 13.7 (SD=7.9) months after death of suicide victim. The family members of the 23 remaining cases either could not be contacted, or an interview could not be arranged, or they refused to participate. The reasons for refusal were related to the intensity of suffering or to fear of being stigmatized. Concerning the sex-ratio, age and ethnicity, the cases in the analysis are representative of the total number of cases of suicide during the study period. There were no significant differences in terms of gender and age between suicide deaths for which an interview was performed and the other suicide deaths during the same period. Sixtyseven percent of cases (n = 35) had one informant, 23% (n = 12) had two informants, two cases had three informants, the three remaining cases had 4, 5 and 16 informants respectively. In the last case, all 16 extended family members participated in the interview, but detailed background information on 14 of them could not be obtained. Seventyfive percent of informants were women, 44% were first degree family members (parents, brothers, sisters, or children), 31% other family members, 11% friends, 8% partners, and 6% others. The mean age was 42. It is important to note that 2014 was an unusual year with respect to sex distribution, as there were fewer male and more female suicides than usual. More specifically, the higher number of female suicides was due to the fact that there were more women in the 15 to 24 age group. The usual number of suicides for that age group never previously exceeded 6 (the average for the period 2000–2013 was less than two per year), but reached 11 in 2014, all of whom were Kanak. Aside from this peculiarity, age structure resembled the usual suicide mortality figures.
recent trends show a decline in the difference between genders. Between 2013 and 2017, the main methods of suicide were by firearm and hanging (both 45%) for men and mainly hanging for women (74%). The WHO/Suicide Trends in at-Risk Territories study (WHO/START) was designed in response to growing concerns about suicide trends in the Western Pacific region (De Leo, Milner, and Xiangdong, 2009; De Leo and Milner, 2010; De Leo et al., 2013). Indeed, at the time of its inception in 2005, the Western Pacific concentrated 38% of all suicides for only a quarter of the world population (WHO, 2004). The main objectives of the WHO/START study were on one hand, to promote the use of a standardized method to record fatal and non-fatal suicidal behaviors to increase the reliability of suicide-related statistics, and on the other hand, to understand the cultural and other factors that influence suicidal behaviors. Indeed, New Caledonia offers a unique opportunity to study suicidal behavior in the indigenous Kanak population compared to other ethnic groups living in the same limited geographical area; for this reason, it was included as a site in the WHO/ START Study in 2013. The present paper examines different aspects of suicide in New Caledonia using the psychological autopsy method. 2. Method 2.1. Data collection The psychological autopsy in suicide research is a method aimed at reconstructing the circumstances of death by collecting data from medical, police records and interviews with close family members. It is one of the main methods for determining and assessing risk and protective factors for suicide death (Almasi et al., 2009; Philipps et al., 2002). The identification and inclusion of suicides in the WHO/START Study database in New Caledonia relied on the findings of judicial and police investigations. According to the Department of Justice, over the two-year study period (between January 2014 and December 2015), 75 suicides occurred in New Caledonia. Personal contact information of family members of all the individuals was obtained from the Justice Department. The interviewer, a clinical psychologist of Kanak origin, contacted all the families and/or other potential informants by telephone and invited them to participate in the study. If no phone number was available, social or health worker intermediaries contacted the family to organize a visit to the home. After a presentation of the study, informed consent was obtained, and an interview was scheduled. The
2.2. Questionnaire/Scales A French version of the WHO/START Study psychological autopsy questionnaire was used. It enabled collection of data including a description of the events and circumstances that led up to death, sociodemographic background, medical and mental health history, and suicide warning signs. Life events during the 12 months prior to death were assessed using the Paykel Life Event Scale (Paykel et al., 1971). An aggression score was calculated using the Overt Aggression Scale (Silver and Yudofsky, 1991). 2
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2.3. Psychiatric diagnoses
Table 1 Social-demographic characteristics of persons who died by suicide in the START PA study (n = 52).
The Structured Clinical Interview (SCID-I), non-patient version (Spitzer et al., 1992) enabled postmortem diagnosis of axis I disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders Text Revised (DSM-IV-TR). The interview was administered by the interviewer, who was a clinical psychologist and had received standardized training prior to the study. Data from the interviews was reviewed by two psychiatrists (BG and TM) during a meeting with the interviewer and a consensus diagnosis was achieved based on the DSM IV-TR diagnostic criteria. Conflicting information between informants was resolved by reviewing medical files and new phone calls with all informants, and a consensus decision was reached between the two psychiatrists and the interviewer.
Total N %
Male N %
Female N %
OR
95% CI L U
Ethnicity Kanak 30 57.7 20 60.6 10 52.6 1 European 10 19.2 6 18.2 4 21.1 0.75 0.17 3.28 inheritance Metis 7 13.5 3 9.1 4 21.1 0.38 0.07 2.01 Other 5 9.6 4 12.1 1 5.3 2.00 0.20 20.33 From an ethnical background that has its own language (other than French) No 11 21.2 7 21.2 4 21.1 1 Yes 41 78.8 26 78.8 15 78.9 0.99 0.25 3.95 Level of fluency in the other language (if applicable) Was fluent 19 47.5 14 53.8 5 35.7 1 7.5 3 11.5 0 0.0 NA Managed to conduct 3 a simple conversation Understood and/or 15 37.5 7 26.9 8 57.1 0.50 0.10 2.46 spoke a few words Did not speak the 3 7.5 2 7.7 1 7.1 1.14 0.08 16.95 language Marital status Married/de facto 21 40.4 15 45.5 6 31.6 1 Single 22 42.3 13 39.4 9 47.4 0.58 0.16 2.06 Separated 6 11.5 2 6.1 4 21.1 0.20 0.03 1.40 Divorced/Widowed 3 5.8 3 9.1 0 0 NA Education* Less than 10th Grade 17 34.7 11 36.7 6 31.6 1.63 0.41 6.46 10th Grade 9 18.4 7 23.3 2 10.5 3.11 0.50 19.54 12th Grade 17 34.7 9 30.0 8 42.1 1 TAFE 2 4.1 1 3.3 1 5.3 0.89 0.05 16.66 University 4 8.2 2 6.7 2 10.5 0.89 0.10 7.86 Employment status Employed 31 59.6 23 69.7 8 42.1 1 Unemployed 7 13.5 4 12.1 3 15.8 0.46 0.08 2.54 Out of workforce 14 26.9 6 18.2 8 42.1 0.26 0.07 0.99 Religion No religion 13 25.0 9 27.3 4 21.1 1 Catholic 23 44.2 16 48.5 7 36.8 1.02 0.23 4.44 Protestant 12 23.1 8 24.2 4 21.1 0.89 0.17 4.78 Other 4 7.7 0 0 4 21.1 NA
2.4. Ethics The study was approved by the French Advisory Committee on the Treatment of Information in Health Research (CCTIRS N°14.084) and the New Caledonia Ethics Advisory Committee for Life Sciences and Health (Avis du 3 Janvier 2014). 2.5. Statistical analysis Descriptive information was transformed into statistical data. To compare groups by sex, age and ethnicity, Odds Ratios (OR) with their respective 95% confidence intervals (95%CI), and significance level (p) were calculated for categorical variables and Fisher's exact test was used when the expected numbers were less than 5. Student's t-test was used for continuous variables. Considering that 29 years was the median age for suicide, the cases were divided into two, under 30 vs. 30 and over. Statistical analyses were performed using the IBM SPSS 25.0. 3. Results The study comprised 33 (63%) men and 19 (37%) women (sex ratio=1.7) who died by suicide with a mean age of 32.5 years (SD=14.6) and median of 29 years. Table 1 presents the sociodemographic characteristics of those who died by suicide by sex and shows that more than half (58%) were Kanak, 19% were of European descent (mainly born in metropolitan France), 14% were metis the majority of whom were a mixture of Kanak, European, and Polynesian. The remaining were mainly Wallisian, Indonesian, and Vietnamese. The men were significantly older than the women (36 years vs. 26 years, p = 0.019). The Kanak were significantly younger than non-Kanak (26 years vs. 41 years, p = 0.001). Most people who died by suicide had an educational level of 12th grade or below (88%, 43). More than half had a full time or part time job (60%, 31). One-fifth lived alone, and 69% lived at home with someone else (parents, partner, childr....en, or friends). Forty-two percent (42%, 22) of the deceased were single (including those in a steady relationship, but not living with partner), 40% (21) were married or in a de facto relationship, 12% (6) were separated, and 6% (3) were divorced. Three-quarters were religious (mainly Catholic and Protestant). Among the deceased, 79% (41) belonged to a group in which French was not the main language. The majority (64%, 33) spoke one of the 35 Kanak languages. Nineteen were fluent and three managed to conduct a simple conversation. Eighteen percent (9) of the deceased had been adopted.
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education unknown=3 females.
and current major depressive episodes (MDE) were most prevalent (35%), followed by alcohol use disorders (33%), and other substance use disorders (29%). Psychotic and associated symptoms were diagnosed in 19%, adjustment disorders in 10% and substance induced mood disorders in 6% of cases. Analyses by sex, age, and ethnic subgroups (Kanak vs. non-Kanak) are presented in Table 2. Some differences by sex where close to the significance level of 0.05, and are worth mentioning. A past MDE was more often present in females (p = 0.058), whereas psychotic and associated symptoms (p = 0.072), and alcohol use disorders (p = 0.068) were more frequent in males. The older age group was significantly more likely to present a current MDE than the younger group (p = 0.027). Prevalence of at least one mental disorder was similar in Kanak and non-Kanak people who died by suicide (61% vs. 64%). Kanak were significantly more likely to present psychotic and associated symptoms (p = 0.021). Past MDE (p = 0.063) and adjustment disorders (p = 0.068) were more prevalent in the non-Kanak ethnic group than the Kanak group, but did not quite reach significance level. 3.2. Warning signs of suicidality
3.1. Mental disorders A third (34%) of women and a quarter of men (25%) who died by suicide had already made a suicide attempt during their lifetime; 12% of women and 13% of men had done so in the year preceding their death. Statements of hopelessness were the most frequent suicide indicator (44%), followed by communications of suicidal intent in the last
At least one mental disorder was evidenced in 62% of suicide cases (Table 2). Thirty four percent of suicide victims had at least two comorbid disorders; 26% (13 cases) had two disorders, 2% (1 case) had three disorders, 2% (1 case) had four and 4% (2 cases) had seven. Past 3
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Table 2 Percentage of males and females presenting a mental disorder in the START PA study (n = 52) MDE = Major depressive episode. Psychiatric condition
Any diagnosis Current MDE Past MDE Substance induced mood disorders Adjustment disorder Psychotic and associated symptoms Alcohol use disorders Other substance use disorders
Any diagnosis Current MDE Past MDE Substance induced mood disorders Adjustment disorder Psychotic and associated symptoms Alcohol use disorders Other substance use disorders
Any diagnosis Current MDE Past MDE Substance induced mood disorders Adjustment disorder Psychotic and associated symptoms Alcohol use disorders Other substance use disorders
Male N
%
Female N
%
22 8 1 2 5 9 14 10
66.7 25.0 3.1 6.5 15.2 27.3 42.4 30.3
9 5 4 1 0 1 3 5
52.9 26.3 21.1 5.3 0 5.3 15.8 27.8
Below 30 N
%
30 and over N
%
14 3 2 0 2 6 9 8
56.0 11.5 7.4 0 7.4 22.2 33.3 30.8
17 10 3 3 3 4 8 7
68.0 40.0 12.5 12.5 12.0 16.0 32.0 28.0
Kanak N
%
Other ethnicity N
%
17 5 1 0 2 9 12 10
60.7 17.2 3.3 0 6.7 30.0 40.0 34.5
14 8 4 3 3 1 5 5
63.6 36.4 19.0 14.3 13.6 4.5 22.7 22.7
OR (95% CI)
p-value
1.78 (0.54–5.88) 0.93 (0.26–3.42) Fisher's exact test = 0.058 Fisher's exact test = 1.000 Fisher's exact test = 0.145 Fisher's exact test = 0.072 Fisher's exact test = 0.068 1.13 (0.32–4.03)
0.344 0.917
0.850
0.60 (0.19–1.90) Fisher's exact test = 0.027 Fisher's exact test = 0.656 Fisher's exact test = 0.103 Fisher's exact test = 0.662 Fisher's exact test = 0.729 1.06 (0.33–3.39) 1.14 (0.34–3.82)
0.382
0.88 (0.28–2.80) 0.37 (0.10–1.33) Fisher's exact test = 0.063 Fisher's exact test = 0.068 Fisher's exact test = 0.638 Fisher's exact test = 0.021 2.27 (0.67–7.80) 1.79 (0.51–6.29)
0.833 0.121
0.918 0.828
0.190 0.361
separation (p = 0.008) were most common in the older age group. Major financial difficulties were significantly more common in the nonKanak group (p = 0.007), while the ‘death of close family’ was more prevalent in Kanaks (p = 0.033).
year (39%). Nearly 30% had been exposed to a death by suicide in their close relationships, and one out of four had behaviors or made other statements indicative of being suicidal. In 24% of the cases, the family was aware of the suicidal state. Males were significantly more likely than females to have purchased a firearm (p = 0.040; Table 3). The 30 and older age group was also significantly more likely to have obtained a firearm (p = 0.039) and to have had behaviors or made statements (other than hopelessness) indicative of being suicidal (p = 0.025). Non-Kanak individuals were significantly more likely to have had behaviors or made other statements indicative of being suicidal (p = 0.049).
3.5. Aggression There was no difference in the aggression score according to sex. The younger group had a significantly lower aggression score in the year prior to death than the older group (t=−2.51; p = 0.016); but not during the last month (t=−0.93; p = 0.359). Over the last year, the Kanak group had a lower aggression score than the non-Kanak group but the difference was not significant (t=−1.59; p = 0.119) and there was no significant difference in the last month (t = 0.69; p = 0.495). A further analysis according to sex and ethnic group showed that Kanak men had a lower aggression score over the last year than non-Kanak men, and the difference was close to being significant (t=−1.84; p = 0.076); however, this difference disappeared in the last month (t=−0.04; p = 0.969).
3.3. General health Close to 38% had been in contact with a health professional in the three months prior to death, most often with a general practitioner (15%). One-third had a known medical history and were on medication. Members of the 30 and older age group were significantly more likely to have chronic pain (p = 0.004), and the non-Kanak ethnic group was significantly more likely to have a known medical history (OR=0.27; 95%CI=0.08–0.93) and chronic pain (p = 0.011).
4. Discussion
3.4. Life events
The limited literature on suicide among people living in the Pacific Islands has mostly focused on socio-demographic background (Booth, 1999, 2010; Else, 2007; Hezel, 1987; Rubinstein, 2002) and, to our knowledge, this is the first psychological autopsy study in the region. Although suicidal behaviors are not punished in any way in New Caledonia, various social and moral factors, including Christian values, have historically contributed to stigmatization of suicidal behavior. This might also have contributed to explain the lack of research about suicide in New Caledonia even though mortality data has been recorded by the health authorities since 1991. It has been suggested that suicide did not exist before European colonization, but linguistic expressions
Serious arguments with a partner or spouse were the most frequent life events during the preceding year in people who died by suicide (60% total, including 33% with partner and 27% with spouse). Fortyfour percent of individuals were implicated in domestic violence. A quarter had moderate or severe financial difficulties, or had experienced the death of someone close, 23% had a marital separation, 19% had work related problems. Unemployment as a life event was significantly more frequent in females (p = 0.044). Work conditions (p = 0.047), major financial difficulties (p = 0.001), and marital 4
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Table 3 Indications of suicidal state (n = 52).
Suicide attempt in the 12 months prior to suicide Suicide attempt during lifetime Communication of suicide intent in the last year Family aware of suicidality Suicide description in media in recent past Intent to change or did change will Disposal of personal possessions Stockpile pills Acquire firearm Statements of hopelessness Behaviors or other statements indicative of being suicidal SAs in family or close friends Family/close friend died by suicide
Suicide attempt in the 12 months prior to death Suicide attempt during lifetime Communication of suicide intent in the last year Family aware of suicidality Suicide description in media in recent past Intent to change or did change will Disposal of personal possessions Stockpile pills Acquire firearm Statements of hopelessness Behaviors or other statements indicative of being suicidal SAs in family or close friends Family/close friend died by suicide
Suicide attempt in the 12 months prior to death Suicide attempt during lifetime Communication of suicide intent in the last year Family aware of suicidality Suicide description in media in recent past Intent to change or did change will Disposal of personal possessions Stockpile pills Acquire firearm Statements of hopelessness Behaviors or other statements indicative of being suicidal SAs in family or close friends Family/close friend died by suicide
Male N
%
Female N
%
OR (95% CI)
4 8 15 7 3 5 3 3 7 13 8 2 8
12.5 25.0 45.5 22.6 9.7 17.9 9.7 9.7 21.9 39.4 24.2 6.5 25.8
2 6 5 5 3 2 3 3 0 10 5 5 6
11.8 33.6 26.3 26.3 17.6 10.5 15.8 16.7 0 52.6 26.3 27.8 31.6
Below 30 N
%
30 and over N
%
2 6 7 5 4 2 1 1 1 10 3 5 10
7.4 22.2 25.9 19.2 17.6 8.0 3.8 3.8 3.7 37.0 11.1 18.5 37
4 5 13 7 2 5 5 5 6 13 10 2 4
18.2 21.7 52.0 29.2 8.0 22.7 20.8 21.7 26.1 52.0 40.0 9.1 17.6
Kanak N
%
Other ethnicity N
%
2 6 10 5 5 4 2 1 4 11 4 4 10
6.7 20.0 33.3 17.9 19.2 15.4 7.1 3.6 13.3 36.7 13.3 13.3 33.3
4 5 10 7 1 3 4 5 3 12 9 3 4
21.2 25.0 45.5 31.8 4.5 14.3 18.2 23.8 15.0 54.5 40.8 15.8 20.0
Fisher's exact test = 1.000 0.60 (0.15–2.34) 2.33 (0.68–7.98) 0.82 (0.22–3.07) Fisher's exact test = 0.652 Fisher's exact test = 0.685 Fisher's exact test = 0.661 Fisher's exact test = 0.472 Fisher's exact test = 0.040 0.59 (0.19–1.83) 0.90 (0.25–3.27) Fisher's exact test = 0.084 0.75 (0.21–2.65)
Fisher's exact test = 0.388 Fisher's exact test = 1.000 0.32 (0.10–1.04) 0.58 (0.16–2.15) Fisher's exact test = 0.407 Fisher's exact test = 0.157 Fisher's exact test = 0.093 Fisher's exact test = 0.086 Fisher's exact test = 0.039 0.54 (0.18–1.64) Fisher's exact test = 0.025 Fisher's exact test = 0.436 Fisher's exact test = 0.206
Fisher's exact test = 0.190 0.75 (0.19–2.90) 0.60 (0.19–1.86) 0.47 (0.12–1.74) Fisher's exact test = 0.199 Fisher's exact test = 1.000 Fisher's exact test = 0.385 Fisher's exact test = 0.072 Fisher's exact test = 1.000 0.48 (0.16–1.48) Fisher's exact test = 0.049 Fisher's exact test = 1.000 Fisher's exact test = 0.353
p-value
0.459 0.172 0.864
0.355 0.868 0.659
0.053 0.411
0.278
0.676 0.375 0.251
0.200
(Nguyen et al., 2018). Nevertheless, it is comparable with the prevalence found in a nationally representative sample in China (63%: Phillips et al., 2002, and Tong and Phillips, 2010). In China, the authors highlighted the stronger influence of socioeconomic factors, and urban vs. rural life settings compared to Western countries. Similarly, the relatively low prevalence of mental disorders in New Caledonia calls for additional etiological explanations of suicide mortality, possibly comparable to those described in other Pacific Islands. Indeed, rapid social changes among indigenous Pacific Islanders have been incriminated in the rapid and recent increase in suicide rates, especially among the young (Booth, 2010; Else, 2007; Rubinstein, 2002). On the other hand, it should be recalled that in New Caledonia, among those who died by suicide, Kanak and non-Kanak had similar rates of mental disorders, which could contradict the lower odds of mental disorders in indigenous suicides found by De Leo et al. (2012). The relatively frequent use of firearms by men points to their easy access in New Caledonia and could partly explain lower rates of mental disorders among those who died by suicide, because easy access to a very lethal method in case of acute stress could increase suicide risk in the absence of any mental disorder, as suggested by Philips et al. (2002). Compared to the results of the WHO/Mental Health in the General
designating traditional forms of suicide are evidence that some forms of suicidal behaviors existed before that time (Goodfellow, 2018). The present study thus provides unique insight into factors related to suicide at an individual level in a Pacific Island and a comparison between indigenous populations and more recently settled populations. Police and other authorities do not collect information about ethnicity for any cases of death either in metropolitan France or in New Caledonia. However, the present study found that 58% suicide victims were Kanak whereas, according to the 2014 population Census (Institut National de la Statistique et des Etudes Economiques, 2014), Kanak represent 40% of the general population, suggesting a higher risk among Kanak than among other ethnicities in New Caledonia. Furthermore, the Kanak who died by suicide were younger than victims in the other ethnic groups, which is also comparable with data on other indigenous populations in the Western Pacific (Beautrais et al., 2006, De Leo et al., 2011; Hezel, 1987; Rubinstein, 2002). Psychiatric disorders were present in 62% of the people who died by suicide in New Caledonia: this is relatively low compared to the 90% reported in the literature (Cheng et al., 2000; Palacio et al., 2007) and to the 87% found in a case series psychological autopsy study conducted in metropolitan France at the same time as the present study 5
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close in space and over time. This phenomenon has also been described among young men in Micronesia (Hezel, 1987; Rubinstein, 2002). While no clear links were found between the cases except the time and location, the widespread use of social media and its implication in suicide risk (Luxton et al., 2012) may have contributed to the 2014 suicide cluster.
Population (MHGP) study in New Caledonia, the prevalence of mental disorders in those who died by suicide is still higher than the prevalence in the general population, i.e. 42%, which is already high, owing to a particularly high prevalence of substance use disorders (Calandreau, 2009; Goodfellow et al., 2010). Comparison with the general population should however be undertaken with caution as the sex, age, and ethnic structure of those who died by suicide and the general population differ and the MHGP study was conducted in 2006 and 2008 using a different diagnostic tool (the MINI). Major depressive episodes, alcohol- and drug- (mainly cannabis) related disorders were the most frequent disorders among those who died by suicide, resembling statistics reported in earlier studies (Khan et al., 2008; Nguyen et al., 2018; Phillips et al., 2002) and still more frequent than in the general population (Calandreau, 2009). Surprisngly, while nonKanak people who died by suicide showed similar prevalence of psychotic disorders compared to the general population (5% vs. 4%), there was a much higher prevalence of psychotic disorder among Kanak people who died by suicide than among the general population (30% vs. 2%). This suggests vulnerability to suicide among Kanak individuals with a psychotic disorder. The most frequent life event was serious arguments with a partner or a spouse (60%) and 44% of suicide decedents were indeed involved in domestic violence. This suggests the arguments may have involved some form of violence. A sociological study conducted in New Caledonia identified a relationship between incurred violence and suicidal ideation among women (Hamelin et al., 2008). This and another study (Salomon et al., 2004) evidenced high levels of violence against women in New Caledonia suggesting that conflict with a partner and especially violent conflict is an important factor leading to suicide in New Caledonia. Suicide may be perceived and used locally as a ‘weapon against the oppressor’ as noted by Barbagli (2015) in China and in some indigenous populations in Pacific Islands, including New Caledonia. The author described how suicide was used by victims of unfair treatment, unable to use any other way to retaliate against someone in a position of power. Suicide was thus perceived as the result of injustice and often entailed severe social consequences for the person considered as the oppressor. Furthermore, 23% experienced a recent marital separation, which is also often linked to serious arguments and violence in the relationship and has been also shown to be an important suicide risk factor (Ide et al., 2010). Unemployment has been found to be a suicide risk factor in several studies (Milner et al., 2013). Somewhat surprisingly, in the present study, 13% of persons who died by suicide were unemployed, which is almost the same as the unemployment rate in New Caledonia (12% by the Institut de la statistique et des études économiques de NouvelleCalédonie, 2017). This suggests that unemployment may not be a risk factor for suicide in New Caledonia. Earlier studies showed that a previous suicide attempt is an important suicide risk factor (Palacio et al., 2007; Nguyen et al., 2018). In the present study, 25% of men and 33% of women who died by suicide had previously attempted suicide compared to approximately 10% of people living in New Caledonia (Agence Sanitaire et Sociale, 2015; Calandreau, 2009). Overall, warning signs of a suicidal state were less frequent in the younger age group and among Kanak suicide victims, implying unpredictability. Also, these groups were less aggressive, meaning identifying individuals who need help in these groups will be a challenge. Almost 30% of people who died by suicide had already been exposed to suicide among those close to them, suggesting possible suicide contagion and clusters. Suicide clusters have been said to be more frequent in youth (Haw et al., 2013). Furthermore, Cheung et al. (2014) revealed that in Australia, clusters were more frequent among Aboriginal and Torres Strait Islanders than in the general population, suggesting indigenous populations may be more vulnerable. The 2014 peak in the frequency of suicide in the 15–24 female Kanak age group (n = 11) seems to have the features of a suicide cluster as they occurred
5. Study strengths and limitations A few limitations of the study should be noted. Firstly, absence of a control group that would enable determination of risk and protective factors for suicide. Nevertheless, existing studies in the general population in New Caledonia made it possible to give some perspectives to the discussion. Second, the small number of cases included in the study limits its statistical power. However, our response rate was 69%, which is comparable to other psychological autopsy studies (Foster et al., 1999; Nguyen et al., 2018). Furthermore, while earlier studies reported difficulties in recruiting indigenous relatives to the psychological autopsy studies (e.g. in Australia: de Leo et al., 2013), our study included a rather large proportion of indigenous Kanak people. It is important to note that the interviewer (ACS) in the present study is a Kanak, which helped reach out to Kanak families and insured the data collected are reliable. The third limitation was the relatively small number of informants, as only 33% of cases had more than one informant. The fourth limitation is that neither the SCID nor any other scale used in the study have been standardized to the local population of New Caledonia. The other limitations are related to the psychological autopsy method itself, i.e. the interviewer, recall, and emotional biases (Almasi et al., 2009; Nguyen et al., 2018; Phillips et al., 2002). For these reasons, the interviewer's training was standardized and the study questionnaire was a French version of the one used in other WHO/START study sites. No interviews were conducted sooner than three months after the death of the suicide victim. 6. Implications for prevention Despite the good coverage and quality of the health care system, including psychiatric care, across the entire archipelago, mental health disorders and previous suicide attempts are highly prevalent suicide risk factors in New Caledonia, like in other countries. Efforts should thus be invested in encouraging help-seeking by those with mental health disorders and in the case of non-fatal suicidal behaviors, with close attention to and follow-up for those who attempt suicide, especially in the year following the attempt. As evidenced in a previous survey in New Caledonia (Calandreau, 2009), reducing social stigma linked to mental health could be an avenue to encourage help seeking behaviors. Furthermore, there is a need to establish more solid ties between mental health services and various sectors of social welfare (e.g. unemployment help desks, police and justice departments, couple counseling services, local churches and indigenous customary authorities). The indigenous Kanak population was found to be overrepresented among those who died by suicide calling for a focus on this population and for culturally appropriate means of prevention. Hopelessness and suicide indicators (including aggressive behaviors) were found to be less frequent among the young people and Kanak. Given the fewer prediction possibilities in these populations, suicide prevention could be a major challenge. Nonetheless, in addition to the attention normally paid to general suicide risk factors, particular attention should be paid to these populations, using socially and culturally appropriate methods of communication. The occurrence of a suicide cluster during the study period suggests the importance of postvention activities. Taken together, these points underline the need for research and prevention tools based on electronic media, as already attempted among Aboriginal Australians (Tighe et al., 2017). The particularly high rate of argument-related life events between 6
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partners calls for intricate prevention strategies and close attention to domestic violence. Separation, especially when associated with other suicide risk factors, should be the object of special care and prevention.
Cheung, Y.T., Spittal, M.J., Williamson, M.K., Tung, S.J., Pirkis, J, 2014. Predictors of suicides occurring within suicide clusters in Australia, 2004–2008. Soc. Sci. Med. 118, 135–142. De Leo, D., Milner, A., 2010. The who/start study: promoting suicide prevention for a diverse range of cultural contexts. Suicide Life Threat Behav. 40 (2), 99–106. De Leo, D., Milner, A., Fleischmann, A., Bertolote, J., Collings, S., Amadeo, S., Wang, X., 2013. The who start study: suicidal behaviors across different areas of the world. Crisis 34 (3), 156–163. De Leo, D., Milner, A., Sveticic, J., 2012. Mental disorders and communication of intent to die in indigenous suicide cases, Queensland, Australia. Suicide Life‐Threatening Behav. 42 (2), 136–146. De Leo, D., Sveticic, J., Milner, A., 2011. Suicide in indigenous people in Queensland, Australia: trends and methods, 1994–2007. Aust. New Zealand J. Psychiatry 45 (7), 532–538. De Leo, D., Milner, A., Xiangdong, W., 2009. Suicidal behavior in the Western Pacific region: characteristics and trends. Suicide Life Threat Behav. 39 (1), 72–81. Foster, T., Gillespie, K., McLelland, R., Patterson, C., 1999. Risk factors for suicide independent of DSM–III–R axis i disorder: case–control psychological autopsy study in Northern Ireland. Br. J. Psychiatry 175 (2), 175–179. Goodfellow, B., Calandreau, F., Roelandt, J.-.L., 2010. Psychiatric epidemiology in New Caledonia. Int. J. Ment. Health 39 (1), 68–81. https://doi.org/10.2753/IMH00207411390104. Goodfellow, B., 2018. Terms and Definitions for Suicide: Steps Towards the Elaboration of an International and Intercultural Nomenclature for Suicidal Behaviours. Griffith University, Brisbane. Hamelin, C., Salomon, C., Lert, F., Vignier, N., Bonenfant, S., Kanieswski, N., Carole, C., 2008. Situation Sociale Et Comportements De Santé Des Jeunes En NouvelleCalédonie. INSERM, Villejuif. Haw, C., Hawton, K., Niedzwiedz, C., Platt, S, 2013. Suicide clusters: A review of risk factors and mechanisms. Suicide Life-Threatening Behav. 43 (1), 97–108. Hezel, F., 1987. Truk suicide epidemic and social change. Hum. Organ. 46 (4), 283–291. Ide, N., Wyder, M., Kolves, K., De Leo, D., 2010. Separation as an important risk factor for suicide: A systematic review. J. Fam. Issues 31 (12), 1689–1716. Institut National de la Statistique et des Etudes Economiques. (2014). Recensement de la population de nouvelle-calédonie. Retrieved Avril 2019 https://www.insee.fr/fr/ statistiques/1560282. Institut de la statistique et des études économiques de Nouvelle-Calédonie. (2017). Emploi-chômage. Retrieved Mars 2019 http://www.isee.nc/population/18-emploirevenus/emploi-conditions-de-travail/2-emploi-chomage. Khan, M.M., Mahmud, S., Karim, M.S., Zaman, M., Prince, M., 2008. Case–control study of suicide in Karachi, Pakistan. Br. J. Psychiatry 193 (5), 402–405. Luxton, D.D., June, J.D., Fairall, J.M., 2012. Social media and suicide: a public health perspective. Am. J. Public Health 102 (2), S195–S200. https://doi.org/10.2105/ AJPH.2011.300608. Milner, A., Hjelmeland, H., Arensman, E., De Leo, D., 2013. Social-environmental factors and suicide mortality: a narrative review of over 200 articles. Sociol. Mind 3 (2), 137–148. https://doi.org/10.4236/sm.2013.32021. In. DOI:. Nguyen, M., Peter, F., Geslin, G., Hassan, F., 2018. Déterminants et facteurs précipitants des décès par suicide dans le département de la Sarthe et leur relation avec les soins en santé mentale. Agence Régionale de Santé, Pays de Loire. Palacio, C., García, J., Diago, J., Zapata, C., Lopez, G., Ortiz, J., Lopez, M., 2007. Identification of suicide risk factors in medellín, colombia: a case-control study of psychological autopsy in a developing country. Arch. Suicide Res. 11 (3), 297–308. https://doi.org/10.1080/13811110600894223. Paykel, E.S., Prusoff, B.A., Uhlenhuth, E., 1971. Scaling of life events. Arch. Gen. Psychiatry 25 (4), 340–347. 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 (9347), 1728–1736. https://doi.org/10.1016/S0140-6736(02)11681-3. Rubinstein, D.H., 2002. Youth suicide and social change in micronesia. 南太平洋海域調査 研究報告=Occasional papers 36, 33–41. Salomon, C., Hamelin, C., Goldberg, P., Sitta, R., Cyr, D., Nakache, J.P., Goldberg, M., 2004. Premiers Résultats De L'enquête santé, Conditions De Vie Et De Sécurité Des Femmes Calédoniennes. INSERM. Silver, J.M., Yudofsky, S.C., 1991. The overt aggression scale: overview and guiding principles. J Neuropsychiatry Clin. Neurosci. 3 (2), S22–S29. Spitzer, R.L., Williams, J.B., Gibbon, M., First, M.B., 1992. The structured clinical interview for DSM-III-R (SCID): I: history, rationale, and description. Arch. Gen. Psychiatry 49 (8), 624–629. Tighe, J., Shand, F., Ridani, R., Mackinnon, A., De La Mata, N., Christensen, H., 2017. Ibobbly mobile health intervention for suicide prevention in australian indigenous youth: a pilot randomised controlled trial. BMJ Open 7 (1), e013518. Tong, Y., Phillips, M.R., 2010. Cohort-specific risk of suicide for different mental disorders in China. Br. J. Psychiatry 196 (6), 467–473. World Health Organization, 2004. World Health Report 2004: Changing History. WHO, Geneva Retrieved 2 March 2019: https://www.who.int/whr/2004/en/. World Health Organization, 2018. Global Health Observatory Data Repository. Retrieved 2 March 2019. http://apps.who.int/gho/data/view.main.MHSUICIDEASDRv.
7. Conclusion The WHO/START Study psychological study in New Caledonia revealed features of suicide that are specific to this archipelago while also exhibiting similarities with worldwide trends of increasing youth and female suicide mortality. Serious arguments with one's partner, especially violent arguments, appear to be a strong risk factor for suicide in New Caledonia. Despite the lower prevalence of any mental disorder compared to Western countries, having a mental disorder is nevertheless an important risk factor for suicide in New Caledonia. Relatively few indicators of a suicidal state were identified among the younger generations and among the Kanak population, which calls for innovative and culturally appropriate methods of prevention as well as continued research. Contributors BG locally coordinated the study and wrote the manuscript draft; KK did the data analysis and critically reviewed the manuscript; ACS was the local WHO/START interviewer and critically reviewed the manuscript; TM critically reviewed the manuscript; SA critically reviewed the manuscript; DDL is the main investigator of the WHO/START Study and critically reviewed the manuscript. All authors have approved the final article. Declaration of Competing Interest None Acknowledgements We are truly indebted to all the families and other informants who participated in the interviews. We thank the Government of New Caledonia which funded this study in its entirety. We are also indebted to Mrs. Christine Salomon, Dr. Sylvie Laumond, Mr. Gregoire Thibouville for their help interpreting results, and Mrs. Daphne Goodfellow for her help in language editing. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jad.2019.11.020. References Agence Sanitaire et Sociale. (2015). Baromètre santé adulte Retrieved Mars 2019 https:// www.ass.nc/etudes-et-recherches/barometres-sante/barometre-sante-adulte-2015. Almasi, K., Belso, N., Kapur, N., Webb, R., Cooper, J., Hadley, S., Rihmer, Z., 2009. Risk factors for suicide in Hungary: a case-control study. BMC Psychiatry 9 (1), 45. Barbagli, M., 2015. Farewell to the world: a History of Suicide. Polity Books, Cambridge. Booth, H., 1999. Pacific island suicide in comparative perspective. J. Biosoc. Sci. 31 (4), 433–448. Booth, H., 2010. The evolution of epidemic suicide on Guam: context and contagion. Suicide Life Threat Behav. 40 (1), 1–13. Calandreau, F., 2009. Santé mentale en Nouvelle-Calédonie: images et réalités Retrieved from. http://docplayer.fr/17700765-Sante-mentale-en-nouvelle-caledonie-imageset-realites.html. Cheng, A.T., Chen, T.H., Chen, C.-.C., Jenkins, R., 2000. Psychosocial and psychiatric risk factors for suicide: Case-control psychological autopsy study. Br. J. Psychiatry 177 (4), 360–365.
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Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research paper
The WHO/START study in New Caledonia: A psychological autopsy case series ⁎
Benjamin Goodfellowa,b, , Kairi Kõlvesa, Anne-Cécile Selefenc, Tiffany Massainb, Stéphane Amadéod, Diego De Leoa a Australian Institute of Suicide Research and Prevention, World Health Organization Collaborating Centre for Research in Suicide Prevention and Training, Griffith University, Mt Gravatt, Australia b Centre Hospitalier Albert Bousquet, Nouméa, New Caledonia c Direction de la Sécurité Publique de la Nouvelle-Calédonie, Nouméa, New Caledonia d Departement of Psychiatry, Centre Hospitalier de Polynésie Française, Association SOS Suicide, French Polynesia
A R T I C LE I N FO
A B S T R A C T
Keywords: Suicide Psychological autopsy Pacific Islands Cultural factors
Background: Limited information is available about suicidal behavior in the Pacific Islands. Forty percent of the New Caledonian population is indigenous Kanak; insights into the characteristics of suicide deaths in this population compared to other ethnic groups would be valuable. The aim of this paper is to deepen our understanding of the cultural underpinnings of suicide in New Caledonia by presenting the results of the WHO/START psychological autopsy study. Method: A case-series psychological autopsy study was conducted based on medical, police files, and interviews with relatives of 52 individuals who died by suicide in 2014 and 2015 in New Caledonia. Results: Kanak indigenous individuals represented more than half of suicides. Prevalence of mental disorders was identified in 62% of suicide decedents; a previous suicide attempt was frequent (37% of cases). A serious argument with a partner was the most prevalent life event (60%). Few warning signs were present among young people and Kanak in general. Conclusion: Comparison with information on the general population suggests indigenous Kanak are more vulnerable and that having a mental health disorder plays an important role in suicide. Violent arguments with a partner could also be a major risk factor. Traditional protective factors (being employed, living with their family or partner, religion) appeared to have limited effect on suicide. Mental health promotion, prevention, and care should be prioritized. Prevention strategies, including domestic violence prevention are recommended in New Caledonia. Further research is needed to better identify young and Kanak subjects at risk of suicide.
1. Introduction New Caledonia has been the scene of struggle between old tribes for land for nearly three thousand years, and since the European colonization in the 19th century, struggles and rebellions by the indigenous Kanak people have never ceased. However, this tropical island paradise on the edge of the Coral Sea has also been a land of peaceful coexistence between different ethnic groups since the Noumea Treaty in 1998. On the one hand, the treaty acknowledges the cultural identity and privileged access to land for the Kanak indigenous people in New Caledonia, and on the other, the possibility for this French overseas territory to become independent after a process of referendums. The different people who coexist in New Caledonia now appear to share one burden,
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that of unnecessary premature death, including suicide. New Caledonia is a tropical archipelago located in the Western Pacific, about 1000 km north of Australia and New Zealand. It was first colonized by Austronesian settlers approximately 1000 BCE. European colonization began in the 19th century. Currently, New Caledonia's population is close to 300,000, mainly indigenous Kanak (40%) and people of European, Polynesian and Asian descent. Suicide rates in New Caledonia have been relatively stable, close to 15 per 100,000 since 1991, when suicide mortality started to be officially recorded by the local health authorities (Fig. 1). This rate is higher than the global 10.5 suicide rate in 2016 (WHO, 2018) and than the 12.1 rate in metropolitan France (WHO, 2018). At close to 3 to 1, the male to female ratio resembles that in the majority of Western countries, however,
Corresponding author at: Centre Hospitalier Albert Bousquet, Nouméa, New Caledonia E-mail address: [email protected] (B. Goodfellow).
https://doi.org/10.1016/j.jad.2019.11.020 Received 26 May 2019; Received in revised form 4 September 2019; Accepted 8 November 2019 Available online 09 November 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
Please cite this article as: Benjamin Goodfellow, et al., Journal of Affective Disorders, https://doi.org/10.1016/j.jad.2019.11.020
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Fig. 1. Age-standardized suicide rates in New Caledonia (1991–2017, per 100,000, medical death certificates, WHO world standard population). Source: Direction des Affaires Sanitaires et Sociales, Nouvelle-Calédonie.
interview lasted between 2 and 4 h and was conducted face to face by a trained interviewer. Conflicting information between informants was resolved by renewed phone calls with all the informants. The relatives of 52 suicide victims agreed to take part in the study, giving a participation rate of 69.3%. Interviews were conducted on average 13.7 (SD=7.9) months after death of suicide victim. The family members of the 23 remaining cases either could not be contacted, or an interview could not be arranged, or they refused to participate. The reasons for refusal were related to the intensity of suffering or to fear of being stigmatized. Concerning the sex-ratio, age and ethnicity, the cases in the analysis are representative of the total number of cases of suicide during the study period. There were no significant differences in terms of gender and age between suicide deaths for which an interview was performed and the other suicide deaths during the same period. Sixtyseven percent of cases (n = 35) had one informant, 23% (n = 12) had two informants, two cases had three informants, the three remaining cases had 4, 5 and 16 informants respectively. In the last case, all 16 extended family members participated in the interview, but detailed background information on 14 of them could not be obtained. Seventyfive percent of informants were women, 44% were first degree family members (parents, brothers, sisters, or children), 31% other family members, 11% friends, 8% partners, and 6% others. The mean age was 42. It is important to note that 2014 was an unusual year with respect to sex distribution, as there were fewer male and more female suicides than usual. More specifically, the higher number of female suicides was due to the fact that there were more women in the 15 to 24 age group. The usual number of suicides for that age group never previously exceeded 6 (the average for the period 2000–2013 was less than two per year), but reached 11 in 2014, all of whom were Kanak. Aside from this peculiarity, age structure resembled the usual suicide mortality figures.
recent trends show a decline in the difference between genders. Between 2013 and 2017, the main methods of suicide were by firearm and hanging (both 45%) for men and mainly hanging for women (74%). The WHO/Suicide Trends in at-Risk Territories study (WHO/START) was designed in response to growing concerns about suicide trends in the Western Pacific region (De Leo, Milner, and Xiangdong, 2009; De Leo and Milner, 2010; De Leo et al., 2013). Indeed, at the time of its inception in 2005, the Western Pacific concentrated 38% of all suicides for only a quarter of the world population (WHO, 2004). The main objectives of the WHO/START study were on one hand, to promote the use of a standardized method to record fatal and non-fatal suicidal behaviors to increase the reliability of suicide-related statistics, and on the other hand, to understand the cultural and other factors that influence suicidal behaviors. Indeed, New Caledonia offers a unique opportunity to study suicidal behavior in the indigenous Kanak population compared to other ethnic groups living in the same limited geographical area; for this reason, it was included as a site in the WHO/ START Study in 2013. The present paper examines different aspects of suicide in New Caledonia using the psychological autopsy method. 2. Method 2.1. Data collection The psychological autopsy in suicide research is a method aimed at reconstructing the circumstances of death by collecting data from medical, police records and interviews with close family members. It is one of the main methods for determining and assessing risk and protective factors for suicide death (Almasi et al., 2009; Philipps et al., 2002). The identification and inclusion of suicides in the WHO/START Study database in New Caledonia relied on the findings of judicial and police investigations. According to the Department of Justice, over the two-year study period (between January 2014 and December 2015), 75 suicides occurred in New Caledonia. Personal contact information of family members of all the individuals was obtained from the Justice Department. The interviewer, a clinical psychologist of Kanak origin, contacted all the families and/or other potential informants by telephone and invited them to participate in the study. If no phone number was available, social or health worker intermediaries contacted the family to organize a visit to the home. After a presentation of the study, informed consent was obtained, and an interview was scheduled. The
2.2. Questionnaire/Scales A French version of the WHO/START Study psychological autopsy questionnaire was used. It enabled collection of data including a description of the events and circumstances that led up to death, sociodemographic background, medical and mental health history, and suicide warning signs. Life events during the 12 months prior to death were assessed using the Paykel Life Event Scale (Paykel et al., 1971). An aggression score was calculated using the Overt Aggression Scale (Silver and Yudofsky, 1991). 2
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2.3. Psychiatric diagnoses
Table 1 Social-demographic characteristics of persons who died by suicide in the START PA study (n = 52).
The Structured Clinical Interview (SCID-I), non-patient version (Spitzer et al., 1992) enabled postmortem diagnosis of axis I disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders Text Revised (DSM-IV-TR). The interview was administered by the interviewer, who was a clinical psychologist and had received standardized training prior to the study. Data from the interviews was reviewed by two psychiatrists (BG and TM) during a meeting with the interviewer and a consensus diagnosis was achieved based on the DSM IV-TR diagnostic criteria. Conflicting information between informants was resolved by reviewing medical files and new phone calls with all informants, and a consensus decision was reached between the two psychiatrists and the interviewer.
Total N %
Male N %
Female N %
OR
95% CI L U
Ethnicity Kanak 30 57.7 20 60.6 10 52.6 1 European 10 19.2 6 18.2 4 21.1 0.75 0.17 3.28 inheritance Metis 7 13.5 3 9.1 4 21.1 0.38 0.07 2.01 Other 5 9.6 4 12.1 1 5.3 2.00 0.20 20.33 From an ethnical background that has its own language (other than French) No 11 21.2 7 21.2 4 21.1 1 Yes 41 78.8 26 78.8 15 78.9 0.99 0.25 3.95 Level of fluency in the other language (if applicable) Was fluent 19 47.5 14 53.8 5 35.7 1 7.5 3 11.5 0 0.0 NA Managed to conduct 3 a simple conversation Understood and/or 15 37.5 7 26.9 8 57.1 0.50 0.10 2.46 spoke a few words Did not speak the 3 7.5 2 7.7 1 7.1 1.14 0.08 16.95 language Marital status Married/de facto 21 40.4 15 45.5 6 31.6 1 Single 22 42.3 13 39.4 9 47.4 0.58 0.16 2.06 Separated 6 11.5 2 6.1 4 21.1 0.20 0.03 1.40 Divorced/Widowed 3 5.8 3 9.1 0 0 NA Education* Less than 10th Grade 17 34.7 11 36.7 6 31.6 1.63 0.41 6.46 10th Grade 9 18.4 7 23.3 2 10.5 3.11 0.50 19.54 12th Grade 17 34.7 9 30.0 8 42.1 1 TAFE 2 4.1 1 3.3 1 5.3 0.89 0.05 16.66 University 4 8.2 2 6.7 2 10.5 0.89 0.10 7.86 Employment status Employed 31 59.6 23 69.7 8 42.1 1 Unemployed 7 13.5 4 12.1 3 15.8 0.46 0.08 2.54 Out of workforce 14 26.9 6 18.2 8 42.1 0.26 0.07 0.99 Religion No religion 13 25.0 9 27.3 4 21.1 1 Catholic 23 44.2 16 48.5 7 36.8 1.02 0.23 4.44 Protestant 12 23.1 8 24.2 4 21.1 0.89 0.17 4.78 Other 4 7.7 0 0 4 21.1 NA
2.4. Ethics The study was approved by the French Advisory Committee on the Treatment of Information in Health Research (CCTIRS N°14.084) and the New Caledonia Ethics Advisory Committee for Life Sciences and Health (Avis du 3 Janvier 2014). 2.5. Statistical analysis Descriptive information was transformed into statistical data. To compare groups by sex, age and ethnicity, Odds Ratios (OR) with their respective 95% confidence intervals (95%CI), and significance level (p) were calculated for categorical variables and Fisher's exact test was used when the expected numbers were less than 5. Student's t-test was used for continuous variables. Considering that 29 years was the median age for suicide, the cases were divided into two, under 30 vs. 30 and over. Statistical analyses were performed using the IBM SPSS 25.0. 3. Results The study comprised 33 (63%) men and 19 (37%) women (sex ratio=1.7) who died by suicide with a mean age of 32.5 years (SD=14.6) and median of 29 years. Table 1 presents the sociodemographic characteristics of those who died by suicide by sex and shows that more than half (58%) were Kanak, 19% were of European descent (mainly born in metropolitan France), 14% were metis the majority of whom were a mixture of Kanak, European, and Polynesian. The remaining were mainly Wallisian, Indonesian, and Vietnamese. The men were significantly older than the women (36 years vs. 26 years, p = 0.019). The Kanak were significantly younger than non-Kanak (26 years vs. 41 years, p = 0.001). Most people who died by suicide had an educational level of 12th grade or below (88%, 43). More than half had a full time or part time job (60%, 31). One-fifth lived alone, and 69% lived at home with someone else (parents, partner, childr....en, or friends). Forty-two percent (42%, 22) of the deceased were single (including those in a steady relationship, but not living with partner), 40% (21) were married or in a de facto relationship, 12% (6) were separated, and 6% (3) were divorced. Three-quarters were religious (mainly Catholic and Protestant). Among the deceased, 79% (41) belonged to a group in which French was not the main language. The majority (64%, 33) spoke one of the 35 Kanak languages. Nineteen were fluent and three managed to conduct a simple conversation. Eighteen percent (9) of the deceased had been adopted.
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education unknown=3 females.
and current major depressive episodes (MDE) were most prevalent (35%), followed by alcohol use disorders (33%), and other substance use disorders (29%). Psychotic and associated symptoms were diagnosed in 19%, adjustment disorders in 10% and substance induced mood disorders in 6% of cases. Analyses by sex, age, and ethnic subgroups (Kanak vs. non-Kanak) are presented in Table 2. Some differences by sex where close to the significance level of 0.05, and are worth mentioning. A past MDE was more often present in females (p = 0.058), whereas psychotic and associated symptoms (p = 0.072), and alcohol use disorders (p = 0.068) were more frequent in males. The older age group was significantly more likely to present a current MDE than the younger group (p = 0.027). Prevalence of at least one mental disorder was similar in Kanak and non-Kanak people who died by suicide (61% vs. 64%). Kanak were significantly more likely to present psychotic and associated symptoms (p = 0.021). Past MDE (p = 0.063) and adjustment disorders (p = 0.068) were more prevalent in the non-Kanak ethnic group than the Kanak group, but did not quite reach significance level. 3.2. Warning signs of suicidality
3.1. Mental disorders A third (34%) of women and a quarter of men (25%) who died by suicide had already made a suicide attempt during their lifetime; 12% of women and 13% of men had done so in the year preceding their death. Statements of hopelessness were the most frequent suicide indicator (44%), followed by communications of suicidal intent in the last
At least one mental disorder was evidenced in 62% of suicide cases (Table 2). Thirty four percent of suicide victims had at least two comorbid disorders; 26% (13 cases) had two disorders, 2% (1 case) had three disorders, 2% (1 case) had four and 4% (2 cases) had seven. Past 3
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Table 2 Percentage of males and females presenting a mental disorder in the START PA study (n = 52) MDE = Major depressive episode. Psychiatric condition
Any diagnosis Current MDE Past MDE Substance induced mood disorders Adjustment disorder Psychotic and associated symptoms Alcohol use disorders Other substance use disorders
Any diagnosis Current MDE Past MDE Substance induced mood disorders Adjustment disorder Psychotic and associated symptoms Alcohol use disorders Other substance use disorders
Any diagnosis Current MDE Past MDE Substance induced mood disorders Adjustment disorder Psychotic and associated symptoms Alcohol use disorders Other substance use disorders
Male N
%
Female N
%
22 8 1 2 5 9 14 10
66.7 25.0 3.1 6.5 15.2 27.3 42.4 30.3
9 5 4 1 0 1 3 5
52.9 26.3 21.1 5.3 0 5.3 15.8 27.8
Below 30 N
%
30 and over N
%
14 3 2 0 2 6 9 8
56.0 11.5 7.4 0 7.4 22.2 33.3 30.8
17 10 3 3 3 4 8 7
68.0 40.0 12.5 12.5 12.0 16.0 32.0 28.0
Kanak N
%
Other ethnicity N
%
17 5 1 0 2 9 12 10
60.7 17.2 3.3 0 6.7 30.0 40.0 34.5
14 8 4 3 3 1 5 5
63.6 36.4 19.0 14.3 13.6 4.5 22.7 22.7
OR (95% CI)
p-value
1.78 (0.54–5.88) 0.93 (0.26–3.42) Fisher's exact test = 0.058 Fisher's exact test = 1.000 Fisher's exact test = 0.145 Fisher's exact test = 0.072 Fisher's exact test = 0.068 1.13 (0.32–4.03)
0.344 0.917
0.850
0.60 (0.19–1.90) Fisher's exact test = 0.027 Fisher's exact test = 0.656 Fisher's exact test = 0.103 Fisher's exact test = 0.662 Fisher's exact test = 0.729 1.06 (0.33–3.39) 1.14 (0.34–3.82)
0.382
0.88 (0.28–2.80) 0.37 (0.10–1.33) Fisher's exact test = 0.063 Fisher's exact test = 0.068 Fisher's exact test = 0.638 Fisher's exact test = 0.021 2.27 (0.67–7.80) 1.79 (0.51–6.29)
0.833 0.121
0.918 0.828
0.190 0.361
separation (p = 0.008) were most common in the older age group. Major financial difficulties were significantly more common in the nonKanak group (p = 0.007), while the ‘death of close family’ was more prevalent in Kanaks (p = 0.033).
year (39%). Nearly 30% had been exposed to a death by suicide in their close relationships, and one out of four had behaviors or made other statements indicative of being suicidal. In 24% of the cases, the family was aware of the suicidal state. Males were significantly more likely than females to have purchased a firearm (p = 0.040; Table 3). The 30 and older age group was also significantly more likely to have obtained a firearm (p = 0.039) and to have had behaviors or made statements (other than hopelessness) indicative of being suicidal (p = 0.025). Non-Kanak individuals were significantly more likely to have had behaviors or made other statements indicative of being suicidal (p = 0.049).
3.5. Aggression There was no difference in the aggression score according to sex. The younger group had a significantly lower aggression score in the year prior to death than the older group (t=−2.51; p = 0.016); but not during the last month (t=−0.93; p = 0.359). Over the last year, the Kanak group had a lower aggression score than the non-Kanak group but the difference was not significant (t=−1.59; p = 0.119) and there was no significant difference in the last month (t = 0.69; p = 0.495). A further analysis according to sex and ethnic group showed that Kanak men had a lower aggression score over the last year than non-Kanak men, and the difference was close to being significant (t=−1.84; p = 0.076); however, this difference disappeared in the last month (t=−0.04; p = 0.969).
3.3. General health Close to 38% had been in contact with a health professional in the three months prior to death, most often with a general practitioner (15%). One-third had a known medical history and were on medication. Members of the 30 and older age group were significantly more likely to have chronic pain (p = 0.004), and the non-Kanak ethnic group was significantly more likely to have a known medical history (OR=0.27; 95%CI=0.08–0.93) and chronic pain (p = 0.011).
4. Discussion
3.4. Life events
The limited literature on suicide among people living in the Pacific Islands has mostly focused on socio-demographic background (Booth, 1999, 2010; Else, 2007; Hezel, 1987; Rubinstein, 2002) and, to our knowledge, this is the first psychological autopsy study in the region. Although suicidal behaviors are not punished in any way in New Caledonia, various social and moral factors, including Christian values, have historically contributed to stigmatization of suicidal behavior. This might also have contributed to explain the lack of research about suicide in New Caledonia even though mortality data has been recorded by the health authorities since 1991. It has been suggested that suicide did not exist before European colonization, but linguistic expressions
Serious arguments with a partner or spouse were the most frequent life events during the preceding year in people who died by suicide (60% total, including 33% with partner and 27% with spouse). Fortyfour percent of individuals were implicated in domestic violence. A quarter had moderate or severe financial difficulties, or had experienced the death of someone close, 23% had a marital separation, 19% had work related problems. Unemployment as a life event was significantly more frequent in females (p = 0.044). Work conditions (p = 0.047), major financial difficulties (p = 0.001), and marital 4
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Table 3 Indications of suicidal state (n = 52).
Suicide attempt in the 12 months prior to suicide Suicide attempt during lifetime Communication of suicide intent in the last year Family aware of suicidality Suicide description in media in recent past Intent to change or did change will Disposal of personal possessions Stockpile pills Acquire firearm Statements of hopelessness Behaviors or other statements indicative of being suicidal SAs in family or close friends Family/close friend died by suicide
Suicide attempt in the 12 months prior to death Suicide attempt during lifetime Communication of suicide intent in the last year Family aware of suicidality Suicide description in media in recent past Intent to change or did change will Disposal of personal possessions Stockpile pills Acquire firearm Statements of hopelessness Behaviors or other statements indicative of being suicidal SAs in family or close friends Family/close friend died by suicide
Suicide attempt in the 12 months prior to death Suicide attempt during lifetime Communication of suicide intent in the last year Family aware of suicidality Suicide description in media in recent past Intent to change or did change will Disposal of personal possessions Stockpile pills Acquire firearm Statements of hopelessness Behaviors or other statements indicative of being suicidal SAs in family or close friends Family/close friend died by suicide
Male N
%
Female N
%
OR (95% CI)
4 8 15 7 3 5 3 3 7 13 8 2 8
12.5 25.0 45.5 22.6 9.7 17.9 9.7 9.7 21.9 39.4 24.2 6.5 25.8
2 6 5 5 3 2 3 3 0 10 5 5 6
11.8 33.6 26.3 26.3 17.6 10.5 15.8 16.7 0 52.6 26.3 27.8 31.6
Below 30 N
%
30 and over N
%
2 6 7 5 4 2 1 1 1 10 3 5 10
7.4 22.2 25.9 19.2 17.6 8.0 3.8 3.8 3.7 37.0 11.1 18.5 37
4 5 13 7 2 5 5 5 6 13 10 2 4
18.2 21.7 52.0 29.2 8.0 22.7 20.8 21.7 26.1 52.0 40.0 9.1 17.6
Kanak N
%
Other ethnicity N
%
2 6 10 5 5 4 2 1 4 11 4 4 10
6.7 20.0 33.3 17.9 19.2 15.4 7.1 3.6 13.3 36.7 13.3 13.3 33.3
4 5 10 7 1 3 4 5 3 12 9 3 4
21.2 25.0 45.5 31.8 4.5 14.3 18.2 23.8 15.0 54.5 40.8 15.8 20.0
Fisher's exact test = 1.000 0.60 (0.15–2.34) 2.33 (0.68–7.98) 0.82 (0.22–3.07) Fisher's exact test = 0.652 Fisher's exact test = 0.685 Fisher's exact test = 0.661 Fisher's exact test = 0.472 Fisher's exact test = 0.040 0.59 (0.19–1.83) 0.90 (0.25–3.27) Fisher's exact test = 0.084 0.75 (0.21–2.65)
Fisher's exact test = 0.388 Fisher's exact test = 1.000 0.32 (0.10–1.04) 0.58 (0.16–2.15) Fisher's exact test = 0.407 Fisher's exact test = 0.157 Fisher's exact test = 0.093 Fisher's exact test = 0.086 Fisher's exact test = 0.039 0.54 (0.18–1.64) Fisher's exact test = 0.025 Fisher's exact test = 0.436 Fisher's exact test = 0.206
Fisher's exact test = 0.190 0.75 (0.19–2.90) 0.60 (0.19–1.86) 0.47 (0.12–1.74) Fisher's exact test = 0.199 Fisher's exact test = 1.000 Fisher's exact test = 0.385 Fisher's exact test = 0.072 Fisher's exact test = 1.000 0.48 (0.16–1.48) Fisher's exact test = 0.049 Fisher's exact test = 1.000 Fisher's exact test = 0.353
p-value
0.459 0.172 0.864
0.355 0.868 0.659
0.053 0.411
0.278
0.676 0.375 0.251
0.200
(Nguyen et al., 2018). Nevertheless, it is comparable with the prevalence found in a nationally representative sample in China (63%: Phillips et al., 2002, and Tong and Phillips, 2010). In China, the authors highlighted the stronger influence of socioeconomic factors, and urban vs. rural life settings compared to Western countries. Similarly, the relatively low prevalence of mental disorders in New Caledonia calls for additional etiological explanations of suicide mortality, possibly comparable to those described in other Pacific Islands. Indeed, rapid social changes among indigenous Pacific Islanders have been incriminated in the rapid and recent increase in suicide rates, especially among the young (Booth, 2010; Else, 2007; Rubinstein, 2002). On the other hand, it should be recalled that in New Caledonia, among those who died by suicide, Kanak and non-Kanak had similar rates of mental disorders, which could contradict the lower odds of mental disorders in indigenous suicides found by De Leo et al. (2012). The relatively frequent use of firearms by men points to their easy access in New Caledonia and could partly explain lower rates of mental disorders among those who died by suicide, because easy access to a very lethal method in case of acute stress could increase suicide risk in the absence of any mental disorder, as suggested by Philips et al. (2002). Compared to the results of the WHO/Mental Health in the General
designating traditional forms of suicide are evidence that some forms of suicidal behaviors existed before that time (Goodfellow, 2018). The present study thus provides unique insight into factors related to suicide at an individual level in a Pacific Island and a comparison between indigenous populations and more recently settled populations. Police and other authorities do not collect information about ethnicity for any cases of death either in metropolitan France or in New Caledonia. However, the present study found that 58% suicide victims were Kanak whereas, according to the 2014 population Census (Institut National de la Statistique et des Etudes Economiques, 2014), Kanak represent 40% of the general population, suggesting a higher risk among Kanak than among other ethnicities in New Caledonia. Furthermore, the Kanak who died by suicide were younger than victims in the other ethnic groups, which is also comparable with data on other indigenous populations in the Western Pacific (Beautrais et al., 2006, De Leo et al., 2011; Hezel, 1987; Rubinstein, 2002). Psychiatric disorders were present in 62% of the people who died by suicide in New Caledonia: this is relatively low compared to the 90% reported in the literature (Cheng et al., 2000; Palacio et al., 2007) and to the 87% found in a case series psychological autopsy study conducted in metropolitan France at the same time as the present study 5
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close in space and over time. This phenomenon has also been described among young men in Micronesia (Hezel, 1987; Rubinstein, 2002). While no clear links were found between the cases except the time and location, the widespread use of social media and its implication in suicide risk (Luxton et al., 2012) may have contributed to the 2014 suicide cluster.
Population (MHGP) study in New Caledonia, the prevalence of mental disorders in those who died by suicide is still higher than the prevalence in the general population, i.e. 42%, which is already high, owing to a particularly high prevalence of substance use disorders (Calandreau, 2009; Goodfellow et al., 2010). Comparison with the general population should however be undertaken with caution as the sex, age, and ethnic structure of those who died by suicide and the general population differ and the MHGP study was conducted in 2006 and 2008 using a different diagnostic tool (the MINI). Major depressive episodes, alcohol- and drug- (mainly cannabis) related disorders were the most frequent disorders among those who died by suicide, resembling statistics reported in earlier studies (Khan et al., 2008; Nguyen et al., 2018; Phillips et al., 2002) and still more frequent than in the general population (Calandreau, 2009). Surprisngly, while nonKanak people who died by suicide showed similar prevalence of psychotic disorders compared to the general population (5% vs. 4%), there was a much higher prevalence of psychotic disorder among Kanak people who died by suicide than among the general population (30% vs. 2%). This suggests vulnerability to suicide among Kanak individuals with a psychotic disorder. The most frequent life event was serious arguments with a partner or a spouse (60%) and 44% of suicide decedents were indeed involved in domestic violence. This suggests the arguments may have involved some form of violence. A sociological study conducted in New Caledonia identified a relationship between incurred violence and suicidal ideation among women (Hamelin et al., 2008). This and another study (Salomon et al., 2004) evidenced high levels of violence against women in New Caledonia suggesting that conflict with a partner and especially violent conflict is an important factor leading to suicide in New Caledonia. Suicide may be perceived and used locally as a ‘weapon against the oppressor’ as noted by Barbagli (2015) in China and in some indigenous populations in Pacific Islands, including New Caledonia. The author described how suicide was used by victims of unfair treatment, unable to use any other way to retaliate against someone in a position of power. Suicide was thus perceived as the result of injustice and often entailed severe social consequences for the person considered as the oppressor. Furthermore, 23% experienced a recent marital separation, which is also often linked to serious arguments and violence in the relationship and has been also shown to be an important suicide risk factor (Ide et al., 2010). Unemployment has been found to be a suicide risk factor in several studies (Milner et al., 2013). Somewhat surprisingly, in the present study, 13% of persons who died by suicide were unemployed, which is almost the same as the unemployment rate in New Caledonia (12% by the Institut de la statistique et des études économiques de NouvelleCalédonie, 2017). This suggests that unemployment may not be a risk factor for suicide in New Caledonia. Earlier studies showed that a previous suicide attempt is an important suicide risk factor (Palacio et al., 2007; Nguyen et al., 2018). In the present study, 25% of men and 33% of women who died by suicide had previously attempted suicide compared to approximately 10% of people living in New Caledonia (Agence Sanitaire et Sociale, 2015; Calandreau, 2009). Overall, warning signs of a suicidal state were less frequent in the younger age group and among Kanak suicide victims, implying unpredictability. Also, these groups were less aggressive, meaning identifying individuals who need help in these groups will be a challenge. Almost 30% of people who died by suicide had already been exposed to suicide among those close to them, suggesting possible suicide contagion and clusters. Suicide clusters have been said to be more frequent in youth (Haw et al., 2013). Furthermore, Cheung et al. (2014) revealed that in Australia, clusters were more frequent among Aboriginal and Torres Strait Islanders than in the general population, suggesting indigenous populations may be more vulnerable. The 2014 peak in the frequency of suicide in the 15–24 female Kanak age group (n = 11) seems to have the features of a suicide cluster as they occurred
5. Study strengths and limitations A few limitations of the study should be noted. Firstly, absence of a control group that would enable determination of risk and protective factors for suicide. Nevertheless, existing studies in the general population in New Caledonia made it possible to give some perspectives to the discussion. Second, the small number of cases included in the study limits its statistical power. However, our response rate was 69%, which is comparable to other psychological autopsy studies (Foster et al., 1999; Nguyen et al., 2018). Furthermore, while earlier studies reported difficulties in recruiting indigenous relatives to the psychological autopsy studies (e.g. in Australia: de Leo et al., 2013), our study included a rather large proportion of indigenous Kanak people. It is important to note that the interviewer (ACS) in the present study is a Kanak, which helped reach out to Kanak families and insured the data collected are reliable. The third limitation was the relatively small number of informants, as only 33% of cases had more than one informant. The fourth limitation is that neither the SCID nor any other scale used in the study have been standardized to the local population of New Caledonia. The other limitations are related to the psychological autopsy method itself, i.e. the interviewer, recall, and emotional biases (Almasi et al., 2009; Nguyen et al., 2018; Phillips et al., 2002). For these reasons, the interviewer's training was standardized and the study questionnaire was a French version of the one used in other WHO/START study sites. No interviews were conducted sooner than three months after the death of the suicide victim. 6. Implications for prevention Despite the good coverage and quality of the health care system, including psychiatric care, across the entire archipelago, mental health disorders and previous suicide attempts are highly prevalent suicide risk factors in New Caledonia, like in other countries. Efforts should thus be invested in encouraging help-seeking by those with mental health disorders and in the case of non-fatal suicidal behaviors, with close attention to and follow-up for those who attempt suicide, especially in the year following the attempt. As evidenced in a previous survey in New Caledonia (Calandreau, 2009), reducing social stigma linked to mental health could be an avenue to encourage help seeking behaviors. Furthermore, there is a need to establish more solid ties between mental health services and various sectors of social welfare (e.g. unemployment help desks, police and justice departments, couple counseling services, local churches and indigenous customary authorities). The indigenous Kanak population was found to be overrepresented among those who died by suicide calling for a focus on this population and for culturally appropriate means of prevention. Hopelessness and suicide indicators (including aggressive behaviors) were found to be less frequent among the young people and Kanak. Given the fewer prediction possibilities in these populations, suicide prevention could be a major challenge. Nonetheless, in addition to the attention normally paid to general suicide risk factors, particular attention should be paid to these populations, using socially and culturally appropriate methods of communication. The occurrence of a suicide cluster during the study period suggests the importance of postvention activities. Taken together, these points underline the need for research and prevention tools based on electronic media, as already attempted among Aboriginal Australians (Tighe et al., 2017). The particularly high rate of argument-related life events between 6
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partners calls for intricate prevention strategies and close attention to domestic violence. Separation, especially when associated with other suicide risk factors, should be the object of special care and prevention.
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7. Conclusion The WHO/START Study psychological study in New Caledonia revealed features of suicide that are specific to this archipelago while also exhibiting similarities with worldwide trends of increasing youth and female suicide mortality. Serious arguments with one's partner, especially violent arguments, appear to be a strong risk factor for suicide in New Caledonia. Despite the lower prevalence of any mental disorder compared to Western countries, having a mental disorder is nevertheless an important risk factor for suicide in New Caledonia. Relatively few indicators of a suicidal state were identified among the younger generations and among the Kanak population, which calls for innovative and culturally appropriate methods of prevention as well as continued research. Contributors BG locally coordinated the study and wrote the manuscript draft; KK did the data analysis and critically reviewed the manuscript; ACS was the local WHO/START interviewer and critically reviewed the manuscript; TM critically reviewed the manuscript; SA critically reviewed the manuscript; DDL is the main investigator of the WHO/START Study and critically reviewed the manuscript. All authors have approved the final article. Declaration of Competing Interest None Acknowledgements We are truly indebted to all the families and other informants who participated in the interviews. We thank the Government of New Caledonia which funded this study in its entirety. We are also indebted to Mrs. Christine Salomon, Dr. Sylvie Laumond, Mr. Gregoire Thibouville for their help interpreting results, and Mrs. Daphne Goodfellow for her help in language editing. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jad.2019.11.020. References Agence Sanitaire et Sociale. (2015). Baromètre santé adulte Retrieved Mars 2019 https:// www.ass.nc/etudes-et-recherches/barometres-sante/barometre-sante-adulte-2015. Almasi, K., Belso, N., Kapur, N., Webb, R., Cooper, J., Hadley, S., Rihmer, Z., 2009. Risk factors for suicide in Hungary: a case-control study. BMC Psychiatry 9 (1), 45. Barbagli, M., 2015. Farewell to the world: a History of Suicide. Polity Books, Cambridge. Booth, H., 1999. Pacific island suicide in comparative perspective. J. Biosoc. Sci. 31 (4), 433–448. Booth, H., 2010. The evolution of epidemic suicide on Guam: context and contagion. Suicide Life Threat Behav. 40 (1), 1–13. Calandreau, F., 2009. Santé mentale en Nouvelle-Calédonie: images et réalités Retrieved from. http://docplayer.fr/17700765-Sante-mentale-en-nouvelle-caledonie-imageset-realites.html. Cheng, A.T., Chen, T.H., Chen, C.-.C., Jenkins, R., 2000. Psychosocial and psychiatric risk factors for suicide: Case-control psychological autopsy study. Br. J. Psychiatry 177 (4), 360–365.
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