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Women and Parasuicide: a Literature Review

The World Health Organisation's International Classification of Diseases (1992) defines parasuicide as

"An act with nonfatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences."

According to the Samaritans website (1) the term 'parasuicide' refers to 'non-fatal acts of self-harm which arise for a variety of different reasons'. It may be used interchangeably with the terms 'attempted suicide' and 'deliberate self-harm'.

International Research:

The WHO/EURO Multicentre Study of Suicide was set up in 1989 in research centres across Europe, to monitor trends in the epidemiology of parasuicide and conduct follow up investigations with a view to predict future suicidal behaviour. Standardised methodologies are used across all the research centres, and the WHO/EURO study is the largest pool of specific data about suicide attempts in the world. Based on the data collected, the Study has estimated that the average European rate of parasuicide for persons aged over 15 years is 140 per 100,000 for males and 193 per 100,000 females. For each age group the female rate exceeds that of the males, with the highest rate among females in the 15-24 age group and the highest rate among males in the 12-34 age group. Recently, however, it has been found that the female to male ratio, previously thought to be around 2:1, is diminishing; in Ireland it has been close to parity for a number of years (Kelleher, et al, 2000 )(2). Self-poisoning is the most common method used. The Study also found that over 40% of individuals had made previous attempts to kill themselves, and an average of 15% made further attempts.

Looking at factors connected with parasuicide, the WHO/EURO Study found that, compared with the general population, people who attempted suicide were more likely to belong to social categories associated with social destabilisation and poverty. Thus the rate of parasuicide was generally found to be higher in urban, disadvantaged areas, and among single people. Unemployment and low levels of formal education were also found to increase the risk of parasuicide, as were poor coping skills, a diagnosis of mental illness, and substance misuse (alcohol or drugs). According to Kelleher et al:
'Personal psychopathy interacts with the social pressures, including relationship difficulties and loss events, leading to a perceived absence of any choice other than suicidal behaviour. (2000:148)'

The WHO document Highlights on Health in Ireland (3), published in 1998, reported that women in this country are still more likely to attempt suicide than men. However it would appear that men are more likely to succeed in taking their own lives, as the rate for men committing suicide in Ireland is given as 18 per 100,000 population, five times the rate for women, which was found to be 3.6 per 100,000 population. The male suicide rate in this country has been rising continuously since the early 1970s, with an increase of 53% since 1980, and a particularly marked increase among young males aged 15-34. The rate of suicide in Ireland among men has now reached the EU average. The suicide rate for Irish women is one of the lowest in western Europe and has been falling since 1980.

The Samaritans website refers to an unpublished study on parasuicide carried out in Oxford by Hawton, Fagg, Simkin, Bale and Bond in 1995. It found that relationship difficulties were the most common issues referred to by people who attempted suicide. They also found that self-poisoning, particularly with paracetamol, was the method most people used in their attempt to commit suicide. Factors associated with attempted suicide cited by the report included:

• Single marital status (including divorced/widowed people)
• Unemployment
• Social deprivation
• History of physical or sexual abuse
• Alcohol problems
• Social isolation

Research in Ireland:

According to a study produced by AWARE (4), a voluntary organisation that aims to assist people affected by depression:
'In the past fifteen years [in Ireland]an estimated 300 - 800 per 100,000 people over the age of fifteen made a non-fatal suicide attempt, that is ten times more suicide attempts than fatal outcomes. (AWARE, 1998)'

Parasuicide would appear to be a significant, if perhaps somewhat hidden or overlooked, phenomenon. The study goes on to point out that more attention should be paid to suicide attempts, given that it has been estimated that 40 to 60% of suicides are the last in a series of attempts which can range from one to twenty or more episodes. Repetition of suicide attempts is common therefore, AWARE estimated that it 'ranges from 12 to 25%, giving a hundred times greater fatal outcome risk for this group than for the general population. About 1 in every 100 of those who make a suicide attempt die by suicide within a year of the first attempt and they tend to be those who are of an older age group, male, separated, living alone and who have a history of psychiatric illness, alcoholism or physical ill-health and where the previous suicide attempt tended to be serious.' (1998)

The report describes three distinct motives among those who make attempts to take their own lives: those who want to die, those who want to be unconscious and get away from their mental distress for a short while, and those for whom it is an appeal or an attempt to move others. It is those in the first and by far the smallest group, who were most likely to commit suicide.

The AWARE study also made an interesting point with regard to increasing suicide rates among young people. It quoted a study carried out by Diekstra (5), taking a global perspective on suicide and parasuicide, which found that countries that have an increasing suicide rate in young people are also likely to be going through significant social change. It was found that in Europe, the increasing suicide rate in people aged 15 to 24 years was associated with a higher divorce rate, high unemployment, high suicide rate, reduction in the population under the age of 15 years, increase in the percentage of the population over 65 years, more women in the work force and an increase in women in third level education. Other factors associated with an increase in the rate in this age group were an increase in alcohol consumption per head of population and a reduction in church membership.

A report published by the Director of Public Health of the Southern Health Board found that suicide was the principal cause of death in young men aged 20-35 in the area. They were found to be four times more likely to take their own lives than women, and were likely to choose more violent methods (Southern Health Board, 2000)(6).

The most research on the parasuicide phenomenon in Ireland has been carried out within the context of the Registry of Parasuicide set up by the National Suicide Research Foundation (NSRF)(7) . The Registry was launched in January 2001 in Cork by Minister for Health and Children, Micheal Martin, and it is the first of its kind in Europe. The Registry now collects data from all Health Board areas; the Eastern Region was the last to be added when it was included in January 2001 (8) . In all Boards, data are collected from major hospitals with an Accident and Emergency Department. The Registry now covers 37 of the 39 hospitals in the country with 'substantial Accident and Emergency throughput', and it is being gradually extended to include psychiatric units/hospitals and prisons.

The NSRF has estimated that there were around 6,000 cases of parasuicide in Ireland in 2000 alone. Projected figures in the Foundation's latest publication estimate that the total number of cases of parasuicide per year in Ireland currently stands at 10,224.

A pioneering study of parasuicide in Ireland was carried out from 1995 to 1998 by the NSRF in conjunction with the Mid Western and the Southern Health Boards. Every case of hospital referred parasuicide was monitored in the Mid-Western and Southern Health Board regions. In all a total of 708 individuals presented to A&E departments with deliberate self-harm behaviours, 350 of whom were females and 358 males. Just over 40% of those who attempted to commit suicide were in the 15-24 year age group, and 25.5% were in the 25-34 age group. The numbers of females outnumbered those of males in both under 25 age groups (under 15yrs, 25-24 years); in the 35-44 age group; and in the over 65 years age group.

The main method of parasuicide used was found to be overdose, accounting for 80% of females and 59% of males. Cutting was the next most commonly used method, accounting for 31% of males and 13% of females. Drowning was used by 4% females and 3% of males. Hanging was next with 3% of males but only 1 female, and poisoning was used by 1% of males and 1% of females in the survey.

Looking at the socio-economic status of people who had attempted suicide, the largest group were people who were unemployed (greater proportions of men than women), followed by employed people (more women than men in this category)students next (far more women here than men), works at home (more women than men), disabled (more men than women); sheltered employment (all men); retired (2 men, 1 woman).

When the immediate precipitants to the act were examined it was found that large proportions cited 'interpersonal argument' - 64% of the women in the study and 49% of men. Fifty-eight percent of the men in the study said that they were intoxicated at the time of their attempted suicide, as did 32% of the women. Interpersonal difficulties in the form of a relationship break-up were cited by roughly equal proportions of men and women (16.7% of men; 16.8% of women); and bereavement was cited by 12.8% of men and 10.3% of women. There were also similar numbers of men and women who attempted suicide as the result of an impending court case (7% of men and 6 of women). Finally a very small proportion of women only cited exam pressures as the reason for their suicide attempt � 3% of the women in the study in all. Just under a quarter of all those in the study (23%) were found to repeat the act within a two year period.

The latest figures of the National Parasuicide Registry indicate that the female rate of parasuicide is higher than the male rate in every single Health Board area. In the North Western Health Board the female rate is higher than the male by 12% but it was higher in the South Eastern Health Board by 45%, and by 47% in the Southern Health Board. Rates for residents of the Eastern Region were found to be the highest in the country. When the rates of parasuicide among residents of Dublin were compared to the rates of residents of four cities in other regions (Cork, Galway, Limerick and Waterford), it was found that female rates were consistently higher (by between 40 and 50%), whereas female rates were lower than male rates in the cities of Galway and Limerick (National Suicide Research Foundation, 2003).

Ongoing Research:

A study into a new treatment approach for deliberate self harm is currently being carried out in the Southern Mid Western Health Board areas. The study is aiming to show the greater efficacy of a problem-solving training approach for this client group. Findings are due to be reported in 2005.

Prevention of Parasuicide:

According to the American Psychiatric Association Adolescent Suicide Group (1993)(9) , quoted in the report by AWARE on Suicide In Ireland (1998), readily recognisable warning signs of suicide exist, which may be best detected by peers and non-professional adult associates of teenagers. These are:

• repeatedly talking about one's death
• talking of reunions with deceased important persons
• giving away prized possessions
• withdrawal from peers and significant others
• poor coping and problem solving skills in the face of repeated problems
• self-destructive behaviour such as drug and alcohol use, reckless behaviour resulting in accidents, sexual promiscuity and eating disorders
• recent stresses such as loss of a relationship, impending notification to parents of poor school performance or loss of job

However, measures aimed at preventing suicide or at reducing its risk among young people have been found to be problematic. The AWARE study, for example, found that suicide hotlines are only minimally effective in reducing suicidal behaviour; campaigns to increase public awareness of suicide are generally thought to be of high risk, as they can cause alarm, produce a social imitative effect and may normalise suicidal behaviour. School based awareness programmes only have limited effects in changing attitudes and hence may be of little use for the general public. In general, AWARE considered focusing on awareness of depression, alcohol and drug abuse and social problems to be more effective.

According the WHO/EURO Study data, with regard to reducing the rates of repetition, cognitive behavioural therapy has been demonstrated to be effective in several of the research centres, with research ongoing in some of the areas. Other intervention treatments included a scheme whereby suicide attempters are given a card aimed at increasing their awareness of services to which they have access without having to harm themselves. It has also been found that cases managed by the person's own general practitioner may have a lower repetition rate than those managed by hospital services alone. Kelleher et al also mention the debates surrounding the effectiveness of school-based suicide prevention programmes; as an alternative they suggest that it might be more sensible to train teachers as gatekeepers to detect emotional problems and suicidal risk in students and refer them as appropriate. In general, however, they suggest that the prevention of parasuicide has to focus more on social issues such as improving education rates particularly among disadvantaged people and males, improving housing and employment prospects, reducing the use of alcohol and preventing the misuse of drugs.

Conclusion:

It may be seen from the above that the area of parasuicide is one in which research work is on-going and comprehensive. As it has been mentioned, Ireland is the only country in Europe in which a Registry of Parasuicide has been set up, and through it rates of parasuicide are being monitored on an ongoing basis.

The Women's Health Council are glad to note that the data on parasuicide are both comprehensive and disaggregated by gender, with reports recording the differing rates of attempted suicide among men and women. Data on methods of parasuicide, immediate precipitants to the act, age and socio-economic status of parasuicidal persons were also all broken down according to gender in the research, particularly in the data collected by the National Suicide Research Foundation. The Women's Health Council also welcomes the fact that the particular situation of women with regard to parasuicide has been identified as an area for concern by researchers in the area. The Council intends to continue monitoring the area of parasuicide, and has noted that more detailed research, with a primary focus on women, may be required in the future.

For further information, please contact:

Aoife O'Brien, Research Officer, The Women's Health Council

References:

1. http://www.samaritans.org/

2. Kelleher, M.J., Keeley, H.S., Lawlor, M., Chambers, D., McAuliffe, C & Corcoran, P. (2000). 'Parasuicide'. In Contemporary Psychiatry Volume 3: Specific Psychiatric Disorders. London: Springer. Ch 10, pp 143-158.

3. http://www.euro.who.int/document/E62012.pdf

4. AWARE (1998). Suicide In Ireland: A Global Perspective and A National Strategy. Dublin: Aware Publications.

5. Diekstra R. (1991). 'Suicide and Parasuicide: A global perspective'. In S. Montomery & NLM Goeting (Eds) Current Approaches: Suicide and Attempted Suicide - Risk Factors, Management and Prevention. Southampton: Duphar Laboratories.

6. Southern Health Board (2000). Report of the Director of Public Health. Cork: Department of Public Health, Southern Health Board.

7. http://www.ucc.ie/ucc/depts/pubh/links.htm

8. National Suicide Research Foundation (2003). National Parasuicide Registry Ireland, January - June 2002. Cork: National Suicide Research Foundation.

9. American Psychiatric Association Adolescent Suicide Group (1993). Report No. 140. Washington DC: American Psychiatric Press.