title: Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO World Mental Health Surveys.
abstract: BACKGROUND
  Community and clinical data have suggested there is an association between trauma exposure and suicidal behavior (i.e., suicide ideation, plans and attempts). However, few studies have assessed which traumas are uniquely predictive of: the first onset of suicidal behavior, the progression from suicide ideation to plans and attempts, or the persistence of each form of suicidal behavior over time. Moreover, few data are available on such associations in developing countries. The current study addresses each of these issues.
  
  
  RESULTS
  Data on trauma exposure and subsequent first onset of suicidal behavior were collected via structured interviews conducted in the households of 102,245 (age 18+) respondents from 21 countries participating in the WHO World Mental Health Surveys. Bivariate and multivariate survival models tested the relationship between the type and number of traumatic events and subsequent suicidal behavior. A range of traumatic events are associated with suicidal behavior, with sexual and interpersonal violence consistently showing the strongest effects. There is a dose-response relationship between the number of traumatic events and suicide ideation/attempt; however, there is decay in the strength of the association with more events. Although a range of traumatic events are associated with the onset of suicide ideation, fewer events predict which people with suicide ideation progress to suicide plan and attempt, or the persistence of suicidal behavior over time. Associations generally are consistent across high-, middle-, and low-income countries.
  
  
  CONCLUSIONS
  This study provides more detailed information than previously available on the relationship between traumatic events and suicidal behavior and indicates that this association is fairly consistent across developed and developing countries. These data reinforce the importance of psychological trauma as a major public health problem, and highlight the significance of screening for the presence and accumulation of traumatic exposures as a risk factor for suicide ideation and attempt.
authors.affiliation: Department of Psychiatry, Groote Schuur Hospital, Cape Town, South Africa.
authors.forename: Dan J
authors.initials: DJ
authors.lastname: Stein
authors.forename: Wai Tat
authors.initials: WT
authors.lastname: Chiu
authors.forename: Irving
authors.initials: I
authors.lastname: Hwang
authors.forename: Ronald C
authors.initials: RC
authors.lastname: Kessler
authors.forename: Nancy
authors.initials: N
authors.lastname: Sampson
authors.forename: Jordi
authors.initials: J
authors.lastname: Alonso
authors.forename: Guilherme
authors.initials: G
authors.lastname: Borges
authors.forename: Evelyn
authors.initials: E
authors.lastname: Bromet
authors.forename: Ronny
authors.initials: R
authors.lastname: Bruffaerts
authors.forename: Giovanni
authors.initials: G
authors.lastname: de Girolamo
authors.forename: Silvia
authors.initials: S
authors.lastname: Florescu
authors.forename: Oye
authors.initials: O
authors.lastname: Gureje
authors.forename: Yanling
authors.initials: Y
authors.lastname: He
authors.forename: Viviane
authors.initials: V
authors.lastname: Kovess-Masfety
authors.forename: Daphna
authors.initials: D
authors.lastname: Levinson
authors.forename: Herbert
authors.initials: H
authors.lastname: Matschinger
authors.forename: Zeina
authors.initials: Z
authors.lastname: Mneimneh
authors.forename: Yosikazu
authors.initials: Y
authors.lastname: Nakamura
authors.forename: Johan
authors.initials: J
authors.lastname: Ormel
authors.forename: Jose
authors.initials: J
authors.lastname: Posada-Villa
authors.forename: Rajesh
authors.initials: R
authors.lastname: Sagar
authors.forename: Kate M
authors.initials: KM
authors.lastname: Scott
authors.forename: Toma
authors.initials: T
authors.lastname: Tomov
authors.forename: Maria Carmen
authors.initials: MC
authors.lastname: Viana
authors.forename: David R
authors.initials: DR
authors.lastname: Williams
authors.forename: Matthew K
authors.initials: MK
authors.lastname: Nock
mesh_terms: D000328:Adult; D014943:Global Health; D006306:Health Surveys; D006801:Humans; D038622:Internationality; D008603:Mental Health / Q000706:statistics & numerical data*; D008960:Models, Psychological; D015999:Multivariate Analysis; D012307:Risk Factors; D013313:Stress Disorders, Post-Traumatic; D013315:Stress, Psychological / Q000150:complications* / Q000523:psychology; D013405:Suicide / Q000523:psychology*; D013997:Time Factors; D014944:World Health Organization