Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO World Mental Health Surveys.
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.
Stein
Dan J
DJ
Department of Psychiatry, Groote Schuur Hospital, Cape Town, South Africa.
Chiu
Wai Tat
WT
Hwang
Irving
I
Kessler
Ronald C
RC
Sampson
Nancy
N
Alonso
Jordi
J
Borges
Guilherme
G
Bromet
Evelyn
E
Bruffaerts
Ronny
R
de Girolamo
Giovanni
G
Florescu
Silvia
S
Gureje
Oye
O
He
Yanling
Y
Kovess-Masfety
Viviane
V
Levinson
Daphna
D
Matschinger
Herbert
H
Mneimneh
Zeina
Z
Nakamura
Yosikazu
Y
Ormel
Johan
J
Posada-Villa
Jose
J
Sagar
Rajesh
R
Scott
Kate M
KM
Tomov
Toma
T
Viana
Maria Carmen
MC
Williams
David R
DR
Nock
Matthew K
MK
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