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Suicidal behavior during economic hard times Marta Elliott, Dara E Naphan and Barbara L Kohlenberg Int J Soc Psychiatry published online 30 October 2014 DOI: 10.1177/0020764014556391 The online version of this article can be found at: http://isp.sagepub.com/content/early/2014/10/29/0020764014556391
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ISP0010.1177/0020764014556391International Journal of Social PsychiatryElliott et al.
E CAMDEN SCHIZOPH
Original Article
Suicidal behavior during economic hard times
International Journal of Social Psychiatry 1–6 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014556391 isp.sagepub.com
Marta Elliott1, Dara E Naphan2 and Barbara L Kohlenberg3
Abstract Background: Most research on suicide is quantitative, and qualitative research is needed to reveal how individuals subjectively experience and account for suicidal behaviors. Aims: The aim of this study is to learn about the circumstances, motivations and consequences of suicidal behavior among individuals hospitalized for attempted suicide and suicidal ideation during the global economic recession. Methods: In-depth semi-structured interviews were conducted with in-patients hospitalized for suicidal behavior in a state-subsidized public mental hospital and analyzed with framework analysis. Results: Interpersonal conflict in the context of severe economic hardship and inadequate mental health care preceded suicidal behavior, rescue and a subsequent respite from desperate situations. Attempted suicide led to increased attention and concern from loved ones and immediate access to mental health care. Conclusions: Government-subsidized funding for outpatient mental health care should be sustained or increased during economic recessions to protect the most vulnerable from suicidal behavior when it is the only viable path toward immediate psychiatric treatment. Keywords Suicide, narratives, economic hardship, recession, community mental health care
Introduction Suicide is the 10th leading cause of death in the United States, and 370,000 Americans are treated for self-harm in emergency rooms each year (Centers for Disease Control, 2012). Worldwide, over 800,000 individuals commit suicide each year, and suicide was the second leading cause of death among individuals aged 15–29 in 2012 (World Health Organization, 2014). Despite calls for qualitative research on suicidal behavior (Goldney, 2002; Hjelmeland & Knizek, 2010; Leenaars, 2002), few such studies on suicide have been published (e.g. L. A. Brenner et al., 2008; Stack & Wasserman, 2007). This study is based on narrative data from our 2007 interviews with 16 patients in a Nevada state mental hospital hospitalized for self-harm or suicidal ideation that we analyzed using framework analysis (Ritchie & Spencer, 1994). Self-harm refers to deliberate self-poisoning or injury with or without the intent to die, whereas suicidal ideation refers to considering suicide. Of the 16 participants, 12 were hospitalized for selfharm, of whom 9 intended to die and 3 did not, while the remaining 4 were hospitalized for suicidal ideation. In 2007, economic activity declined across the United States and industrialized countries worldwide, and US unemployment was the highest it had been since the 1940s (Elsby, Hobijn, & Sahin, 2010). Economic downturn and
high unemployment are associated with increased psychiatric hospitalizations, in part due to suicidal behavior (M. H. Brenner, 1969). In 2008, reductions in productivity (national gross domestic product divided by hours worked) and labor force participation predicted increased rates of suicide among men across 27 industrialized countries (M. H. Brenner, 2012). During that same recession, unemployment in the United States jumped from 5.8% to 9.6% and the suicide rate increased by 3.8% (Reeves et al., 2012). Economic hard times impact mental health by depriving individuals of employment and by straining budgets that fund community mental health care. Loss of employment entails loss of manifest benefits (e.g. income) and latent benefits (e.g. self-esteem, social support, time structure)
1Department
of Sociology, University of Nevada, Reno, Reno, NV, USA PhD Program in Social Psychology, University of Nevada, Reno, Reno, NV, USA 3Department of Psychiatry and Behavioral Sciences, University of Nevada School of Medicine, Reno, NV, USA 2Interdisciplinary
Corresponding author: Marta Elliott, Department of Sociology, University of Nevada, Reno, 1664 N. Virginia Street, Reno, NV 89557, USA. Email: [email protected]
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International Journal of Social Psychiatry
that predict declines in mental health (Jahoda, 1982). Community mental health care depends on taxable income, employee/employer contributions and state subsidies that decline during recessions (Hodgkin & Karpman, 2010). Therefore, steep cuts are made to mental health care programs just when unemployment and suicidal behavior are increasing (Cooper, 2011; Ostamo, Lahelma, & Lönnqvist, 2001; Reeves et al., 2012). In 2007, Nevada had the fourth highest suicide rate in the country (Office of Suicide Prevention, 2012), with only 5.1 psychiatric beds per 100,000 individuals, compared to 17 per 100,000 nationwide (Torrey, Entsminger, Geller, Stanley, & Jaffe, 2008). Rates of unemployment, bankruptcy, foreclosure and homelessness were also relatively high in Nevada (U.S. National Bureau of Labor Statistics, 2012). Given these economic strains, the only timely route to state-subsidized mental health care was for an individual to be designated an immediate threat to self or others, resulting in a 72-hour hospitalization (Torrey et al., 2008). Suicidal behavior (i.e. ideation, planning, gestures and serious attempts) may be motivated by a desire to escape the emotional pain of unbearable circumstances (Baumeister, 1990; Williams, 1997; Williams & Pollock, 2000), to communicate inner distress, to punish significant others, to reach out for help (Farberow & Shneidman, 1965) and only in some cases, to die (Skogman & Öjehagen, 2003). Suicidal individuals tend to be socially isolated, and to feel hopeless, ineffective, burdensome and depressed (Baumeister, 1990; Hunter & O’Connor, 2003; Joiner, 2005; Joiner, Brown, & Wingate, 2005; O’Connor, 2003). Suicide often occurs when individuals perceive that their psychological pain is intolerable (Shneidman, 1993), a theme expressed quite vividly in the novels of Fyodor Dostoyevky (Foy & Rojcewicz, 1979). Research also shows that suicidal behavior is predicted by multiple stressors, such as a history of child abuse (Dieserud, Forsén, Braverman, & Røysamb, 2002; Joiner et al., 2007), recent stressful life events (Paykel, Prusoff, & Myers, 1975) and interpersonal and economic stressors (Stack & Wasserman, 2007). Suicidal individuals tend to blame themselves for their misfortunes (Baumeister, 1990) and feel trapped with no hope of escape and no chance of rescue (O’Connor, 2003; Williams & Pollock, 2000). While suicide is often considered psychological in nature (Shneidman, Farberow, & Litman, 1984), it is important to also think of it as a multidimensional malaise containing elements that are socially shaped (Leenaars, 1996; Shneidman, 1985). Our interviews pursued these themes, allowing the participants to expand in their own words on their experience.
Methods In 2007, the first (M.E.) and third (B.L.K.) authors conducted in-depth semi-structured interviews with adults
hospitalized in a state facility for people unable to pay for treatment. Each patient was hospitalized after attempting suicide or reporting that they were seriously considering suicide, resulting in a 72-hour hold. The interviews were conducted for research purposes not connected with the patients’ treatment. The study was approved by the institutional review boards of the authors’ university and the Nevada Department of Health and Human Services. Inclusion criteria were being age 18 or older, medically stable, competent to give consent, and hospitalized for actual or threatened self-harm, with or without intent to die. The rationale for interviewing individuals in hospital was to capture their stories close to the time of their suicidal behavior or ideation before substantial narrative reconstruction could take place, and to interview people whose behavior was sufficiently serious so as to be as similar as possible to those who completed suicide. Hospital social workers informed eligible patients of the study. Interested patients met with the researchers who explained the study purposes and sought informed consent. The interviews ranged from 30 to 60 minutes, were audiotaped and transcribed. They included open-ended questions about patients’ recent life circumstances, suicidal intent, mode of rescue, reaction of family and friends, and evaluation of their hospitalization, and close-ended questions on age, gender, race/ethnicity, income, housing situation, level of education, marital and employment status. We analyzed the data using framework analysis, a technique developed for applied policy analysis in healthrelated research (Lacey & Luff, 2001; Ritchie & Spencer, 1994) that follows five stages: (1) familiarization; (2) identifying a thematic framework; (3) indexing; (4) charting and (5) mapping and interpretation. Throughout the analysis, we focused on our original aims of explaining the circumstances, motivations and consequences of suicidal behavior. Familiarization involved immersion in the data by carefully reading the transcripts. The second stage involved lengthy discussions during which we sifted and sorted the data into themes that appeared across multiple narratives. This process included deductive and inductive thinking, since some themes confirmed existing theory and others emerged from the narratives. The third stage of indexing consisted of identifying which data illustrated which themes and color-coding the text according to themes. The fourth stage, charting, involved organizing the data (i.e. the quotations illustrative of themes) into a virtual chart with rows representing participants and columns including data representative of each theme. The final stage of mapping and interpretation involved a search for patterns and structure across the themes identified and indexed in the data and visualized in the chart. The 16 participants ranged in age from 19 to 54. In all, 11 were women, ten were White, 3 were Alaskan Natives, 3 were Hispanic and 6 had college degrees. All were struggling to stay afloat economically, unable to find work and
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Elliott et al. dependent upon others with whom relationships were often precarious (e.g. shaky marriages). More than half lacked secure housing and were living with family, friends, in hotels or on the street. According to their accounts, 12 of the 16 could have died from their behaviors had no one intervened. Suicidal behaviors included overdoses, cutting and one attempted hanging, and tended to be impulsive and unpremeditated, although 10 had attempted suicide at least once before.
Results The results are organized according to the three themes that emerged from the data analysis: (1) precipitating factors, (2) modes of survival and (3) benefits of hospitalization. The precipitating factors were consistent with existing knowledge of suicide, whereas the modes of survival and benefits emerged from the data. We refer to participants with pseudonyms and minimal details to ensure anonymity and present the findings in their own words, thereby giving expression to human experiences that are difficult to convey with numbers and statistics. When asked what led to their suicidal behavior, the participants reported deep disappointment with others (n = 12), extreme financial strain (n = 12) and lack of mental health care or medications (n = 8). In all, 12 individuals attributed their suicidal behavior to shattered expectations in romantic or familial relationships, or sometimes both. For four (25%) of the participants, romantic infidelity and betrayal undermined their trust, making them question their own interpersonal appeal, and whether or not life was worth living. Angela expressed it like this: ‘Well see … I lived here for 30 years … raised my family … had everything I wanted in my life … and then I found out right before my 25th anniversary that my husband was having an affair’, a revelation that sent her spiraling downward into feelings of hopelessness about the future. Lisa also experienced a series of disappointments, ranging from being raped as a child to being taken advantage of by people she believed to be her friends. All 16 participants reported economic hardship that they tended to blame upon themselves. A total of 15 (94%) were unemployed at the time of their hospitalization. In all, 11 (69%) had unstable living situations, including eight (50%) who were living with and dependent on others and four (25%) who had been evicted from their apartments or whose homes had been foreclosed. Whether the participants were dependent on others financially, or were forced to be self-reliant and depend on themselves, they expressed feeling inadequate about their life circumstances and blamed themselves for their situations. Carol, for example, said that financially, ‘this is the worst it’s been’ and ‘it’s my fault for not holding a job’. As Lisa puts it, ‘you’re tired of not sleeping … of not eating. You’re tired of trying to pull all your resources out that you can and everything just keeps falling down behind you and it’s just a snowball effect so, that’s really tough’.
Lack of access to mental health care (n = 6), prescription drugs (n = 6) and medication management (n = 5) also came up frequently, often accompanied by job loss. For example, Angela lost her job and with it, her health insurance that had been paying for anti-depressants, leaving her so depressed that she could not get out of bed for weeks, let alone make money. Sheila explained that before she attempted suicide, she ‘had been out of my meds for about a month and I’ve been trying not to drink alcohol as a substitute when I don’t have meds, but I got so upset’. For George, lacking medications meant hearing voices in his head telling him to kill himself. In each case, problems with medications precipitated feelings of hopelessness and despair. Lacking access to mental health care, they struggled to cope with mental health problems that were compounded by interpersonal conflict and financial hardship. Taken together, the circumstances surrounding suicidal behavior included interpersonal disappointments that overwhelmed the participants emotionally and material hardship and inadequate mental health care that limited their capacity to escape their pain. Next we explore the modes of survival through which each participant avoided death by suicide. Modes of survival for the 12 (75%) who attempted suicide corresponded to suicidal intent. Of the 12 individuals, 6 who indicated that they definitely wanted to die were rescued either by reaching out to talk to someone who then intervened to save them, or by being detected by a family member before they had a chance to die. The three individuals who were not sure if they wanted to die took steps to be saved by calling 911, loosening a noose around the neck, or driving to the hospital before succumbing to overdose. The remaining three who said they did not intend to kill themselves were each discovered by their partner, and were surprised to find that their overdose might have killed them, stating that they only wanted to call attention to their pain, and get a break from their unbearable feelings. In every case, their suicidal behavior led to immediate mental health care. All but 1 of the 12 participants (92%) who had attempted suicide regretted what they had done and felt guilty and ashamed. Most were like Rachel, who said, ‘I know I shouldn’t have done it. It was stupid and crazy and look where I’m at’. In contrast, all four (100%) who were hospitalized for thinking about, but not actually attempting suicide, felt they had not done anything to regret and were still wondering if perhaps they should have committed suicide. Janice, for example, felt like she should ‘have finished it you know?’ wondering if upon leaving the hospital, ‘am I going to still be depressed?’ At the same time, all but 1 of the 12 (92%) who had attempted suicide expressed benefits of having attempted suicide. Those who attempted suicide reported benefits, including being temporarily removed from adverse situations (n = 4) and gaining access to psychiatric care (n = 3). The most common benefit that was reported was having loved ones and
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hospital staff show concern for them. The interpersonal problems that precipitated their suicide attempts seemed to improve for 9 (75%) of the 12 participants once they were hospitalized, such as their family members appearing to realize how distraught they were and concluding that their relationship dynamics needed to change. For example, Sheila was pleased that her husband had re-focused all of his energies on her while she was hospitalized: ‘he just said that both of us are gonna have to work a lot more concentrating on getting me the help I need, making sure I always have my medicine and that I get counseling regularly again’. Taken out of their painful situations, 7 (58%) of the 12 participants who attempted suicide showed signs that their spirits were lifting as they became more optimistic about the prospects of living and recovered their ability to think about the future. For example, Jimmy said he would ‘turn in these six [job] applications [he had] at the house and get a phone and wait for that phone to ring and just keep looking for work’. Angela, too, was optimistic about her future: ‘I think if I have a job and I think that if I’m feeling independent again and getting medication and help, I think that’s gonna make a huge difference in the way I’m feeling’. Carol, who was suffering from addiction, said, ‘I’m feeling much stronger. I’m feeling like I can do this, and I get off these drugs and I’m going to go out and do it’. Indeed, many of the participants reported that they had renewed strength to return to their lives after mentally and physically recuperating in the hospital. They also felt less alone and isolated in the world after meeting other patients in similar situations. As Sarah puts it, ‘it was comforting to know that it’s not just me; that there are seemingly normal people out there who all have the same problems’. None of the participants said they engaged in suicidal behavior with the conscious intent of receiving psychiatric care, although 3 (25%) of the 12 acknowledged that the ensuing treatment was what they had needed before but could not access. For instance, Lisa, who slit her wrists, pointed out that ‘I’m getting free counseling … and people are working with me instead of against me … and I’m seeing … all kinds of different psychologists and they’re giving me tools how to live, and that’s what I needed’. In sum, attempting suicide brought these troubled individuals into the mental health care system, gave them a break from their problems and compelled their families to pay closer attention to them. Moreover, attempting suicide might have been the only means of obtaining these benefits given their personal circumstances and the paucity of resources in their area for people down on their luck, both psychologically and materially.
Discussion The survivors of suicidal ideation or attempted suicide in this study were struggling financially, out of work, without disposable income, stable housing, medical insurance or access to psychiatric care. Severe economic strain imperiled
their personal relationships, interpersonal problems precipitated feelings of defeat and isolation, and financial problems prevented them from escaping their worries or getting the help they needed. The multiplicative effects of these economic and relationship stressors culminated to the point that they felt deeply defeated, isolated and burdensome with no perceived way of escaping their pain or of being rescued other than attempting to end their lives. In addition to supporting theory and research on the predictors of suicidal behavior, these accounts revealed new patterns that merit additional comment and continued exploration in future research. For the most part, the participants’ in-the-moment intentions to engage in suicidal behavior and their retrospective attitudes toward their survival were incongruent. Whether or not the 12 participants who attempted suicide intended to end or to temporarily escape their lives, all but 2 said reported benefits of attempted suicide and were grateful they were still alive. In each case, suicidal behavior spoke louder than words and drew the immediate attention of loved ones and of the mental health care system (Nock, 2008). As Sarah puts it, ‘my intent was to just … go to sleep. Not forever, for the night, and then you know, wake up the next day and start the day over’ and to make her boyfriend notice: ‘to scare him. I don’t know. Make him listen’. Indeed, many survivors of suicide cite wanting to sleep, perhaps because sleeping reduces the demands of consciousness through shutting out external stimuli, and is a biological response to extreme stress which conserves energy (Shneidman, 1966). It may have been a closer ‘brush with death’ that caused those who attempted suicide to appreciate their lives more than those who reported ideation only. Research on neardeath experiences indicates that individuals who experience transcendental phenomena on the threshold of death tend to have a greater appreciation for life thereafter. In fact, approximately 20% of all individuals close to death, whether because of an illness, accident or suicide attempt, later have a greater appreciation for life and a decrease in suicidal ideation (Greyson, 1981). In addition, survivors of attempted suicide may elicit greater care and concern from hospital staff and loved ones than in-patients who stopped short of hurting themselves. Our data suggest that suicidal behavior functions as a cry for help in the sense that those whose suicidal methods are not instantly lethal might reach out and be saved before death arrives. By expressing suicidal ‘cries of pain’ they proclaim their perilous status to the outside world, and sound an alert for rescue. Although we cannot know from these data whether the benefits of attempted suicide were unintended, unconsciously intended or coincidental, it is notable that suicidal behavior, and in particular, attempted suicide, may have been the only viable mechanism of receiving appropriate treatment for these individuals. During economic hard times, the demand for public mental health services increases while the supply of such services tends to decrease (Honberg, Kimball, Diehl,
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Elliott et al. Usher, & Fitzpatrick, 2011). The combination of mental illness and the unavailability of mental health care can leave individuals feeling desperate to escape their situation, as if no one will help them. Funding practices outside of the United States demonstrate that when the economy contracts, increasing access to mental health care can offset the mental health effects of recession. In anticipation of the negative effects of economic hard times on mental health, Great Britain, China and Hong Kong increased mental health care spending at the onset of the global recession by focusing spending on counseling for individuals experiencing mental illness as a result of unemployment (Hodgkin & Karpman, 2010). Such differences in responses to the impact of economic recession could reflect cross-cultural differences in attitudes toward spending on mental health care services (Hodgkin & Karpman, 2010). In anticipation of future economic downturns, the federal and state governments of the United States should ensure timely access to outpatient psychiatric treatment, including medication management, to prevent more serious mental health problems such as attempted suicide. Because the participants in this study self-selected to be interviewed, we cannot know if they are systematically different from those who declined the opportunity, nor can we generalize from these narratives to suicidal individuals in general. Nonetheless, this study is very valuable, being one of the few based on in-depth interviews with individuals so soon after their suicidal behavior whose stories are seldom heard. During economic hard times, with publicly subsidized mental health care cut to the bone, our analysis suggests that suicidal behaviors may be the only viable option for troubled and poverty-stricken individuals to obtain immediate psychiatric care. These implications are very sobering when public resources remain strained, unemployment is still high and deep poverty persists. Although state-subsidized in-patient hospitalization for suicidal individuals is essential, future expansion of state services that reach and serve individuals before they are driven to attempt suicide is critical to protecting the most vulnerable among us. Funding This research was funded by a generous grant from the Nevada Trust Fund for Public Health.
References Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 1, 90–113. Brenner, L. A., Guitierrez, P. M., Cornette, M. M., Betthauser, L. M., Bahraini, N., & Staves, P. J. (2008). A qualitative study of potential suicide risk factors in returning combat veterans. Journal of Mental Health Counseling, 30, 211–225. Brenner, M. H. (1969). Patterns of psychiatric hospitalization among different socioeconomic groups in response to economic stress. The Journal of Nervous and Mental Disease, 148, 31–38.
Brenner, M. H. (2012). Profound unhappiness in the international recession: The case of suicide in industrialized countries. In L. Klein, V. Dalko & M. Wang (Eds.), Regulating competition in stock markets: Antitrust measures to promote fairness and transparency through investor protection and crisis prevention (pp. 27–41). Hoboken, NJ: John Wiley. Centers for Disease Control. (2012). Understanding suicide: Fact sheet. Retrieved from http://www.cdc.gov/ViolencePrevention/pdf/Suicide_FactSheet_2012-a.pdf Cooper, B. (2011). Economic recession and mental health: An overview. Neuropsychiatrie, 25, 113–117. Dieserud, G., Forsén, L., Braverman, M. T., & Røysamb, E. (2002). Negative life events in childhood, psychological problems and suicide attempts in adulthood: A matched case-control study. Archives of Suicide Research, 6, 291–308. Elsby, M., Hobijn, B., & Sahin, A. (2010). The labor market in the great recession. Brookings Papers on Economic Activity, 1, 1–48. Farberow, N. L., & Shneidman, E. S. (Eds.). (1965). The cry for help. New York, NY: McGraw-Hill. Foy, J. L., & Rojcewicz, S. J. (1979). Dosteovsky and suicide. Confinia Psychiatrica, 22, 65–80. Goldney, R. D. (2002). Qualitative and quantitative approaches in suicidology. Archives of Suicide Research, 6, 69–73. Greyson, B. (1981). Near-death experiences and attempted suicide. Suicide and Life-Threatening Behavior, 11, 10–16. Hjelmeland, H., & Knizek, B. L. (2010). Why we need qualitative research in suicidology. Suicide and Life-Threatening Behavior, 40, 74–80. Hodgkin, D., & Karpman, H. E. (2010). Economic crises and public spending on mental health care. International Journal of Mental Health, 39(2), 91–106. Honberg, R., Kimball, A., Diehl, S., Usher, L., & Fitzpatrick, M. (2011). State mental health cuts: A continuing crisis. Retrieved from http://www.nami.org/ContentManagement/ ContentDis-play.cfm?ContentFileID=147768 Hunter, E. C., & O’Connor, R. C. (2003). Hopelessness and future thinking in parasuicide: The role of perfectionism. British Journal of Clinical Psychology, 42, 355–365. Jahoda, M. (1982). Employment and unemployment: A socialpsychological analysis. London, England: Cambridge University Press. Joiner, T. E. (2005). Why people die by suicide. Cambridge, UK: Harvard University Press. Joiner, T. E., Brown, J. S., & Wingate, L. R. (2005). The psychology and neurobiology of suicidal behavior. Annual Review of Psychology, 56, 287–314. Joiner, T. E., Sachs-Ericsson, N. J., Wingate, L. R., Brown, J. S., Anestis, M. D., & Selby, E. A. (2007). Childhood physical and sexual abuse and lifetime number of suicide attempts: A persistent and theoretically important relationship. Behavior Research and Therapy, 45, 539–547. Lacey, A., & Luff, D. (2001). Trent focus for research and development in primary health care: An introduction to qualitative analysis. Nottingham, UK: Trent Focus. Leenaars, A. A. (1996). Suicide: A multidimensional malaise. Suicide and Life-Threatening Behavior, 26, 221–236. Leenaars, A. A. (2002). The quantitative and qualitative in suicidological science: An editorial. Archives of Suicide Research, 6, 1–3.
Downloaded from isp.sagepub.com at Ondokuz Mayis Universitesi on November 11, 2014
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Nock, M. K. (2008). Actions speak louder than words: An elaborated theoretical model of the social functions of selfinjury and other harmful behaviors. Applied & Preventive Psychology, 12, 159–168. O’Connor, R. C. (2003). Suicidal behavior as a cry of pain: Test of a psychological model. Archives of Suicide Research, 7, 297–308. Office of Suicide Prevention. (2012). Suicide in Nevada fact sheet 2012. Retrieved from http://www.leg.state.nv.us/ Session/77th2013/Exhibits/Assembly/HHS/AHHS205E.pdf Ostamo, A., Lahelma, E., & Lönnqvist, J. (2001). Transitions of employment status among suicide attempters during a severe economic recession. Social Science & Medicine, 52, 1741–1750. Paykel, E. S., Prusoff, B. A., & Myers, J. K. (1975). Suicide attempts and recent life events: A controlled comparison. Archives of General Psychiatry, 32, 327–333. Reeves, A., Stuckler, D., McKee, M., Gunnell, D., Chang, S., & Basu, S. (2012). Increase in state suicide rates in the USA during economic recession. The Lancet, 380, 1813–1814. Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman & R. Burgess (Eds.), Analyzing qualitative data (pp. 173–194). London, England: Routledge. Shneidman, E. S. (1966). Orientations towards death: A vital aspect of the study of lives. International Journal of Psychiatry, 2, 167–200. Shneidman, E. S. (1985). Definition of suicide. New York, NY: John Wiley.
Shneidman, E. S. (1993). Commentary: Suicide as psychache. Journal of Nervous and Mental Disease, 181, 145–147. Shneidman, E. S., Farberow, N. L., & Litman, R. E. (1984). The psychology of suicide: A clinician’s guide to evaluation and treatment. Northvale, NJ: Jason Aronson. Skogman, K., & Öjehagen, A. (2003). Motives for suicide: The views of the patients. Archives of Suicide Research, 7, 193–206. Stack, S., & Wasserman, I. (2007). Economic strain and suicide risk: A qualitative analysis. Suicide and Life-Threatening Behavior, 37, 103–112. Torrey, E. F., Entsminger, K., Geller, J., Stanley, J., & Jaffe, D. J. (2008). The shortage of public hospital beds for mentally ill persons. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/the_shortage_of_publichospital_beds.pdf U.S. National Bureau of Labor Statistics. (2012). The recession of 2007–2009. Retrieved from http://www.bls.gov/spotlight/2012/recession/ Williams, J. M. G. (1997). Cry of pain: Understanding suicide and self-harm. London, England: Penguin Books. Williams, J. M. G., & Pollock, L. R. (2000). The psychology of suicidal behavior. In K. Hawton & K. van Heeringen (Eds.), The international handbook of suicide and attempted suicide (pp. 79–93). West Sussex, UK: John Wiley. World Health Organization. (2014). Mental health: Suicide prevention. Retrieved from http://www.who.int/mental_health/ prevention/suicide/suicideprevent/en/
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Suicidal behavior during economic hard times Marta Elliott, Dara E Naphan and Barbara L Kohlenberg Int J Soc Psychiatry published online 30 October 2014 DOI: 10.1177/0020764014556391 The online version of this article can be found at: http://isp.sagepub.com/content/early/2014/10/29/0020764014556391
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>> OnlineFirst Version of Record - Oct 30, 2014 What is This?
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556391 research-article2014
ISP0010.1177/0020764014556391International Journal of Social PsychiatryElliott et al.
E CAMDEN SCHIZOPH
Original Article
Suicidal behavior during economic hard times
International Journal of Social Psychiatry 1–6 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014556391 isp.sagepub.com
Marta Elliott1, Dara E Naphan2 and Barbara L Kohlenberg3
Abstract Background: Most research on suicide is quantitative, and qualitative research is needed to reveal how individuals subjectively experience and account for suicidal behaviors. Aims: The aim of this study is to learn about the circumstances, motivations and consequences of suicidal behavior among individuals hospitalized for attempted suicide and suicidal ideation during the global economic recession. Methods: In-depth semi-structured interviews were conducted with in-patients hospitalized for suicidal behavior in a state-subsidized public mental hospital and analyzed with framework analysis. Results: Interpersonal conflict in the context of severe economic hardship and inadequate mental health care preceded suicidal behavior, rescue and a subsequent respite from desperate situations. Attempted suicide led to increased attention and concern from loved ones and immediate access to mental health care. Conclusions: Government-subsidized funding for outpatient mental health care should be sustained or increased during economic recessions to protect the most vulnerable from suicidal behavior when it is the only viable path toward immediate psychiatric treatment. Keywords Suicide, narratives, economic hardship, recession, community mental health care
Introduction Suicide is the 10th leading cause of death in the United States, and 370,000 Americans are treated for self-harm in emergency rooms each year (Centers for Disease Control, 2012). Worldwide, over 800,000 individuals commit suicide each year, and suicide was the second leading cause of death among individuals aged 15–29 in 2012 (World Health Organization, 2014). Despite calls for qualitative research on suicidal behavior (Goldney, 2002; Hjelmeland & Knizek, 2010; Leenaars, 2002), few such studies on suicide have been published (e.g. L. A. Brenner et al., 2008; Stack & Wasserman, 2007). This study is based on narrative data from our 2007 interviews with 16 patients in a Nevada state mental hospital hospitalized for self-harm or suicidal ideation that we analyzed using framework analysis (Ritchie & Spencer, 1994). Self-harm refers to deliberate self-poisoning or injury with or without the intent to die, whereas suicidal ideation refers to considering suicide. Of the 16 participants, 12 were hospitalized for selfharm, of whom 9 intended to die and 3 did not, while the remaining 4 were hospitalized for suicidal ideation. In 2007, economic activity declined across the United States and industrialized countries worldwide, and US unemployment was the highest it had been since the 1940s (Elsby, Hobijn, & Sahin, 2010). Economic downturn and
high unemployment are associated with increased psychiatric hospitalizations, in part due to suicidal behavior (M. H. Brenner, 1969). In 2008, reductions in productivity (national gross domestic product divided by hours worked) and labor force participation predicted increased rates of suicide among men across 27 industrialized countries (M. H. Brenner, 2012). During that same recession, unemployment in the United States jumped from 5.8% to 9.6% and the suicide rate increased by 3.8% (Reeves et al., 2012). Economic hard times impact mental health by depriving individuals of employment and by straining budgets that fund community mental health care. Loss of employment entails loss of manifest benefits (e.g. income) and latent benefits (e.g. self-esteem, social support, time structure)
1Department
of Sociology, University of Nevada, Reno, Reno, NV, USA PhD Program in Social Psychology, University of Nevada, Reno, Reno, NV, USA 3Department of Psychiatry and Behavioral Sciences, University of Nevada School of Medicine, Reno, NV, USA 2Interdisciplinary
Corresponding author: Marta Elliott, Department of Sociology, University of Nevada, Reno, 1664 N. Virginia Street, Reno, NV 89557, USA. Email: [email protected]
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that predict declines in mental health (Jahoda, 1982). Community mental health care depends on taxable income, employee/employer contributions and state subsidies that decline during recessions (Hodgkin & Karpman, 2010). Therefore, steep cuts are made to mental health care programs just when unemployment and suicidal behavior are increasing (Cooper, 2011; Ostamo, Lahelma, & Lönnqvist, 2001; Reeves et al., 2012). In 2007, Nevada had the fourth highest suicide rate in the country (Office of Suicide Prevention, 2012), with only 5.1 psychiatric beds per 100,000 individuals, compared to 17 per 100,000 nationwide (Torrey, Entsminger, Geller, Stanley, & Jaffe, 2008). Rates of unemployment, bankruptcy, foreclosure and homelessness were also relatively high in Nevada (U.S. National Bureau of Labor Statistics, 2012). Given these economic strains, the only timely route to state-subsidized mental health care was for an individual to be designated an immediate threat to self or others, resulting in a 72-hour hospitalization (Torrey et al., 2008). Suicidal behavior (i.e. ideation, planning, gestures and serious attempts) may be motivated by a desire to escape the emotional pain of unbearable circumstances (Baumeister, 1990; Williams, 1997; Williams & Pollock, 2000), to communicate inner distress, to punish significant others, to reach out for help (Farberow & Shneidman, 1965) and only in some cases, to die (Skogman & Öjehagen, 2003). Suicidal individuals tend to be socially isolated, and to feel hopeless, ineffective, burdensome and depressed (Baumeister, 1990; Hunter & O’Connor, 2003; Joiner, 2005; Joiner, Brown, & Wingate, 2005; O’Connor, 2003). Suicide often occurs when individuals perceive that their psychological pain is intolerable (Shneidman, 1993), a theme expressed quite vividly in the novels of Fyodor Dostoyevky (Foy & Rojcewicz, 1979). Research also shows that suicidal behavior is predicted by multiple stressors, such as a history of child abuse (Dieserud, Forsén, Braverman, & Røysamb, 2002; Joiner et al., 2007), recent stressful life events (Paykel, Prusoff, & Myers, 1975) and interpersonal and economic stressors (Stack & Wasserman, 2007). Suicidal individuals tend to blame themselves for their misfortunes (Baumeister, 1990) and feel trapped with no hope of escape and no chance of rescue (O’Connor, 2003; Williams & Pollock, 2000). While suicide is often considered psychological in nature (Shneidman, Farberow, & Litman, 1984), it is important to also think of it as a multidimensional malaise containing elements that are socially shaped (Leenaars, 1996; Shneidman, 1985). Our interviews pursued these themes, allowing the participants to expand in their own words on their experience.
Methods In 2007, the first (M.E.) and third (B.L.K.) authors conducted in-depth semi-structured interviews with adults
hospitalized in a state facility for people unable to pay for treatment. Each patient was hospitalized after attempting suicide or reporting that they were seriously considering suicide, resulting in a 72-hour hold. The interviews were conducted for research purposes not connected with the patients’ treatment. The study was approved by the institutional review boards of the authors’ university and the Nevada Department of Health and Human Services. Inclusion criteria were being age 18 or older, medically stable, competent to give consent, and hospitalized for actual or threatened self-harm, with or without intent to die. The rationale for interviewing individuals in hospital was to capture their stories close to the time of their suicidal behavior or ideation before substantial narrative reconstruction could take place, and to interview people whose behavior was sufficiently serious so as to be as similar as possible to those who completed suicide. Hospital social workers informed eligible patients of the study. Interested patients met with the researchers who explained the study purposes and sought informed consent. The interviews ranged from 30 to 60 minutes, were audiotaped and transcribed. They included open-ended questions about patients’ recent life circumstances, suicidal intent, mode of rescue, reaction of family and friends, and evaluation of their hospitalization, and close-ended questions on age, gender, race/ethnicity, income, housing situation, level of education, marital and employment status. We analyzed the data using framework analysis, a technique developed for applied policy analysis in healthrelated research (Lacey & Luff, 2001; Ritchie & Spencer, 1994) that follows five stages: (1) familiarization; (2) identifying a thematic framework; (3) indexing; (4) charting and (5) mapping and interpretation. Throughout the analysis, we focused on our original aims of explaining the circumstances, motivations and consequences of suicidal behavior. Familiarization involved immersion in the data by carefully reading the transcripts. The second stage involved lengthy discussions during which we sifted and sorted the data into themes that appeared across multiple narratives. This process included deductive and inductive thinking, since some themes confirmed existing theory and others emerged from the narratives. The third stage of indexing consisted of identifying which data illustrated which themes and color-coding the text according to themes. The fourth stage, charting, involved organizing the data (i.e. the quotations illustrative of themes) into a virtual chart with rows representing participants and columns including data representative of each theme. The final stage of mapping and interpretation involved a search for patterns and structure across the themes identified and indexed in the data and visualized in the chart. The 16 participants ranged in age from 19 to 54. In all, 11 were women, ten were White, 3 were Alaskan Natives, 3 were Hispanic and 6 had college degrees. All were struggling to stay afloat economically, unable to find work and
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Elliott et al. dependent upon others with whom relationships were often precarious (e.g. shaky marriages). More than half lacked secure housing and were living with family, friends, in hotels or on the street. According to their accounts, 12 of the 16 could have died from their behaviors had no one intervened. Suicidal behaviors included overdoses, cutting and one attempted hanging, and tended to be impulsive and unpremeditated, although 10 had attempted suicide at least once before.
Results The results are organized according to the three themes that emerged from the data analysis: (1) precipitating factors, (2) modes of survival and (3) benefits of hospitalization. The precipitating factors were consistent with existing knowledge of suicide, whereas the modes of survival and benefits emerged from the data. We refer to participants with pseudonyms and minimal details to ensure anonymity and present the findings in their own words, thereby giving expression to human experiences that are difficult to convey with numbers and statistics. When asked what led to their suicidal behavior, the participants reported deep disappointment with others (n = 12), extreme financial strain (n = 12) and lack of mental health care or medications (n = 8). In all, 12 individuals attributed their suicidal behavior to shattered expectations in romantic or familial relationships, or sometimes both. For four (25%) of the participants, romantic infidelity and betrayal undermined their trust, making them question their own interpersonal appeal, and whether or not life was worth living. Angela expressed it like this: ‘Well see … I lived here for 30 years … raised my family … had everything I wanted in my life … and then I found out right before my 25th anniversary that my husband was having an affair’, a revelation that sent her spiraling downward into feelings of hopelessness about the future. Lisa also experienced a series of disappointments, ranging from being raped as a child to being taken advantage of by people she believed to be her friends. All 16 participants reported economic hardship that they tended to blame upon themselves. A total of 15 (94%) were unemployed at the time of their hospitalization. In all, 11 (69%) had unstable living situations, including eight (50%) who were living with and dependent on others and four (25%) who had been evicted from their apartments or whose homes had been foreclosed. Whether the participants were dependent on others financially, or were forced to be self-reliant and depend on themselves, they expressed feeling inadequate about their life circumstances and blamed themselves for their situations. Carol, for example, said that financially, ‘this is the worst it’s been’ and ‘it’s my fault for not holding a job’. As Lisa puts it, ‘you’re tired of not sleeping … of not eating. You’re tired of trying to pull all your resources out that you can and everything just keeps falling down behind you and it’s just a snowball effect so, that’s really tough’.
Lack of access to mental health care (n = 6), prescription drugs (n = 6) and medication management (n = 5) also came up frequently, often accompanied by job loss. For example, Angela lost her job and with it, her health insurance that had been paying for anti-depressants, leaving her so depressed that she could not get out of bed for weeks, let alone make money. Sheila explained that before she attempted suicide, she ‘had been out of my meds for about a month and I’ve been trying not to drink alcohol as a substitute when I don’t have meds, but I got so upset’. For George, lacking medications meant hearing voices in his head telling him to kill himself. In each case, problems with medications precipitated feelings of hopelessness and despair. Lacking access to mental health care, they struggled to cope with mental health problems that were compounded by interpersonal conflict and financial hardship. Taken together, the circumstances surrounding suicidal behavior included interpersonal disappointments that overwhelmed the participants emotionally and material hardship and inadequate mental health care that limited their capacity to escape their pain. Next we explore the modes of survival through which each participant avoided death by suicide. Modes of survival for the 12 (75%) who attempted suicide corresponded to suicidal intent. Of the 12 individuals, 6 who indicated that they definitely wanted to die were rescued either by reaching out to talk to someone who then intervened to save them, or by being detected by a family member before they had a chance to die. The three individuals who were not sure if they wanted to die took steps to be saved by calling 911, loosening a noose around the neck, or driving to the hospital before succumbing to overdose. The remaining three who said they did not intend to kill themselves were each discovered by their partner, and were surprised to find that their overdose might have killed them, stating that they only wanted to call attention to their pain, and get a break from their unbearable feelings. In every case, their suicidal behavior led to immediate mental health care. All but 1 of the 12 participants (92%) who had attempted suicide regretted what they had done and felt guilty and ashamed. Most were like Rachel, who said, ‘I know I shouldn’t have done it. It was stupid and crazy and look where I’m at’. In contrast, all four (100%) who were hospitalized for thinking about, but not actually attempting suicide, felt they had not done anything to regret and were still wondering if perhaps they should have committed suicide. Janice, for example, felt like she should ‘have finished it you know?’ wondering if upon leaving the hospital, ‘am I going to still be depressed?’ At the same time, all but 1 of the 12 (92%) who had attempted suicide expressed benefits of having attempted suicide. Those who attempted suicide reported benefits, including being temporarily removed from adverse situations (n = 4) and gaining access to psychiatric care (n = 3). The most common benefit that was reported was having loved ones and
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hospital staff show concern for them. The interpersonal problems that precipitated their suicide attempts seemed to improve for 9 (75%) of the 12 participants once they were hospitalized, such as their family members appearing to realize how distraught they were and concluding that their relationship dynamics needed to change. For example, Sheila was pleased that her husband had re-focused all of his energies on her while she was hospitalized: ‘he just said that both of us are gonna have to work a lot more concentrating on getting me the help I need, making sure I always have my medicine and that I get counseling regularly again’. Taken out of their painful situations, 7 (58%) of the 12 participants who attempted suicide showed signs that their spirits were lifting as they became more optimistic about the prospects of living and recovered their ability to think about the future. For example, Jimmy said he would ‘turn in these six [job] applications [he had] at the house and get a phone and wait for that phone to ring and just keep looking for work’. Angela, too, was optimistic about her future: ‘I think if I have a job and I think that if I’m feeling independent again and getting medication and help, I think that’s gonna make a huge difference in the way I’m feeling’. Carol, who was suffering from addiction, said, ‘I’m feeling much stronger. I’m feeling like I can do this, and I get off these drugs and I’m going to go out and do it’. Indeed, many of the participants reported that they had renewed strength to return to their lives after mentally and physically recuperating in the hospital. They also felt less alone and isolated in the world after meeting other patients in similar situations. As Sarah puts it, ‘it was comforting to know that it’s not just me; that there are seemingly normal people out there who all have the same problems’. None of the participants said they engaged in suicidal behavior with the conscious intent of receiving psychiatric care, although 3 (25%) of the 12 acknowledged that the ensuing treatment was what they had needed before but could not access. For instance, Lisa, who slit her wrists, pointed out that ‘I’m getting free counseling … and people are working with me instead of against me … and I’m seeing … all kinds of different psychologists and they’re giving me tools how to live, and that’s what I needed’. In sum, attempting suicide brought these troubled individuals into the mental health care system, gave them a break from their problems and compelled their families to pay closer attention to them. Moreover, attempting suicide might have been the only means of obtaining these benefits given their personal circumstances and the paucity of resources in their area for people down on their luck, both psychologically and materially.
Discussion The survivors of suicidal ideation or attempted suicide in this study were struggling financially, out of work, without disposable income, stable housing, medical insurance or access to psychiatric care. Severe economic strain imperiled
their personal relationships, interpersonal problems precipitated feelings of defeat and isolation, and financial problems prevented them from escaping their worries or getting the help they needed. The multiplicative effects of these economic and relationship stressors culminated to the point that they felt deeply defeated, isolated and burdensome with no perceived way of escaping their pain or of being rescued other than attempting to end their lives. In addition to supporting theory and research on the predictors of suicidal behavior, these accounts revealed new patterns that merit additional comment and continued exploration in future research. For the most part, the participants’ in-the-moment intentions to engage in suicidal behavior and their retrospective attitudes toward their survival were incongruent. Whether or not the 12 participants who attempted suicide intended to end or to temporarily escape their lives, all but 2 said reported benefits of attempted suicide and were grateful they were still alive. In each case, suicidal behavior spoke louder than words and drew the immediate attention of loved ones and of the mental health care system (Nock, 2008). As Sarah puts it, ‘my intent was to just … go to sleep. Not forever, for the night, and then you know, wake up the next day and start the day over’ and to make her boyfriend notice: ‘to scare him. I don’t know. Make him listen’. Indeed, many survivors of suicide cite wanting to sleep, perhaps because sleeping reduces the demands of consciousness through shutting out external stimuli, and is a biological response to extreme stress which conserves energy (Shneidman, 1966). It may have been a closer ‘brush with death’ that caused those who attempted suicide to appreciate their lives more than those who reported ideation only. Research on neardeath experiences indicates that individuals who experience transcendental phenomena on the threshold of death tend to have a greater appreciation for life thereafter. In fact, approximately 20% of all individuals close to death, whether because of an illness, accident or suicide attempt, later have a greater appreciation for life and a decrease in suicidal ideation (Greyson, 1981). In addition, survivors of attempted suicide may elicit greater care and concern from hospital staff and loved ones than in-patients who stopped short of hurting themselves. Our data suggest that suicidal behavior functions as a cry for help in the sense that those whose suicidal methods are not instantly lethal might reach out and be saved before death arrives. By expressing suicidal ‘cries of pain’ they proclaim their perilous status to the outside world, and sound an alert for rescue. Although we cannot know from these data whether the benefits of attempted suicide were unintended, unconsciously intended or coincidental, it is notable that suicidal behavior, and in particular, attempted suicide, may have been the only viable mechanism of receiving appropriate treatment for these individuals. During economic hard times, the demand for public mental health services increases while the supply of such services tends to decrease (Honberg, Kimball, Diehl,
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Elliott et al. Usher, & Fitzpatrick, 2011). The combination of mental illness and the unavailability of mental health care can leave individuals feeling desperate to escape their situation, as if no one will help them. Funding practices outside of the United States demonstrate that when the economy contracts, increasing access to mental health care can offset the mental health effects of recession. In anticipation of the negative effects of economic hard times on mental health, Great Britain, China and Hong Kong increased mental health care spending at the onset of the global recession by focusing spending on counseling for individuals experiencing mental illness as a result of unemployment (Hodgkin & Karpman, 2010). Such differences in responses to the impact of economic recession could reflect cross-cultural differences in attitudes toward spending on mental health care services (Hodgkin & Karpman, 2010). In anticipation of future economic downturns, the federal and state governments of the United States should ensure timely access to outpatient psychiatric treatment, including medication management, to prevent more serious mental health problems such as attempted suicide. Because the participants in this study self-selected to be interviewed, we cannot know if they are systematically different from those who declined the opportunity, nor can we generalize from these narratives to suicidal individuals in general. Nonetheless, this study is very valuable, being one of the few based on in-depth interviews with individuals so soon after their suicidal behavior whose stories are seldom heard. During economic hard times, with publicly subsidized mental health care cut to the bone, our analysis suggests that suicidal behaviors may be the only viable option for troubled and poverty-stricken individuals to obtain immediate psychiatric care. These implications are very sobering when public resources remain strained, unemployment is still high and deep poverty persists. Although state-subsidized in-patient hospitalization for suicidal individuals is essential, future expansion of state services that reach and serve individuals before they are driven to attempt suicide is critical to protecting the most vulnerable among us. Funding This research was funded by a generous grant from the Nevada Trust Fund for Public Health.
References Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 1, 90–113. Brenner, L. A., Guitierrez, P. M., Cornette, M. M., Betthauser, L. M., Bahraini, N., & Staves, P. J. (2008). A qualitative study of potential suicide risk factors in returning combat veterans. Journal of Mental Health Counseling, 30, 211–225. Brenner, M. H. (1969). Patterns of psychiatric hospitalization among different socioeconomic groups in response to economic stress. The Journal of Nervous and Mental Disease, 148, 31–38.
Brenner, M. H. (2012). Profound unhappiness in the international recession: The case of suicide in industrialized countries. In L. Klein, V. Dalko & M. Wang (Eds.), Regulating competition in stock markets: Antitrust measures to promote fairness and transparency through investor protection and crisis prevention (pp. 27–41). Hoboken, NJ: John Wiley. Centers for Disease Control. (2012). Understanding suicide: Fact sheet. Retrieved from http://www.cdc.gov/ViolencePrevention/pdf/Suicide_FactSheet_2012-a.pdf Cooper, B. (2011). Economic recession and mental health: An overview. Neuropsychiatrie, 25, 113–117. Dieserud, G., Forsén, L., Braverman, M. T., & Røysamb, E. (2002). Negative life events in childhood, psychological problems and suicide attempts in adulthood: A matched case-control study. Archives of Suicide Research, 6, 291–308. Elsby, M., Hobijn, B., & Sahin, A. (2010). The labor market in the great recession. Brookings Papers on Economic Activity, 1, 1–48. Farberow, N. L., & Shneidman, E. S. (Eds.). (1965). The cry for help. New York, NY: McGraw-Hill. Foy, J. L., & Rojcewicz, S. J. (1979). Dosteovsky and suicide. Confinia Psychiatrica, 22, 65–80. Goldney, R. D. (2002). Qualitative and quantitative approaches in suicidology. Archives of Suicide Research, 6, 69–73. Greyson, B. (1981). Near-death experiences and attempted suicide. Suicide and Life-Threatening Behavior, 11, 10–16. Hjelmeland, H., & Knizek, B. L. (2010). Why we need qualitative research in suicidology. Suicide and Life-Threatening Behavior, 40, 74–80. Hodgkin, D., & Karpman, H. E. (2010). Economic crises and public spending on mental health care. International Journal of Mental Health, 39(2), 91–106. Honberg, R., Kimball, A., Diehl, S., Usher, L., & Fitzpatrick, M. (2011). State mental health cuts: A continuing crisis. Retrieved from http://www.nami.org/ContentManagement/ ContentDis-play.cfm?ContentFileID=147768 Hunter, E. C., & O’Connor, R. C. (2003). Hopelessness and future thinking in parasuicide: The role of perfectionism. British Journal of Clinical Psychology, 42, 355–365. Jahoda, M. (1982). Employment and unemployment: A socialpsychological analysis. London, England: Cambridge University Press. Joiner, T. E. (2005). Why people die by suicide. Cambridge, UK: Harvard University Press. Joiner, T. E., Brown, J. S., & Wingate, L. R. (2005). The psychology and neurobiology of suicidal behavior. Annual Review of Psychology, 56, 287–314. Joiner, T. E., Sachs-Ericsson, N. J., Wingate, L. R., Brown, J. S., Anestis, M. D., & Selby, E. A. (2007). Childhood physical and sexual abuse and lifetime number of suicide attempts: A persistent and theoretically important relationship. Behavior Research and Therapy, 45, 539–547. Lacey, A., & Luff, D. (2001). Trent focus for research and development in primary health care: An introduction to qualitative analysis. Nottingham, UK: Trent Focus. Leenaars, A. A. (1996). Suicide: A multidimensional malaise. Suicide and Life-Threatening Behavior, 26, 221–236. Leenaars, A. A. (2002). The quantitative and qualitative in suicidological science: An editorial. Archives of Suicide Research, 6, 1–3.
Downloaded from isp.sagepub.com at Ondokuz Mayis Universitesi on November 11, 2014
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Nock, M. K. (2008). Actions speak louder than words: An elaborated theoretical model of the social functions of selfinjury and other harmful behaviors. Applied & Preventive Psychology, 12, 159–168. O’Connor, R. C. (2003). Suicidal behavior as a cry of pain: Test of a psychological model. Archives of Suicide Research, 7, 297–308. Office of Suicide Prevention. (2012). Suicide in Nevada fact sheet 2012. Retrieved from http://www.leg.state.nv.us/ Session/77th2013/Exhibits/Assembly/HHS/AHHS205E.pdf Ostamo, A., Lahelma, E., & Lönnqvist, J. (2001). Transitions of employment status among suicide attempters during a severe economic recession. Social Science & Medicine, 52, 1741–1750. Paykel, E. S., Prusoff, B. A., & Myers, J. K. (1975). Suicide attempts and recent life events: A controlled comparison. Archives of General Psychiatry, 32, 327–333. Reeves, A., Stuckler, D., McKee, M., Gunnell, D., Chang, S., & Basu, S. (2012). Increase in state suicide rates in the USA during economic recession. The Lancet, 380, 1813–1814. Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman & R. Burgess (Eds.), Analyzing qualitative data (pp. 173–194). London, England: Routledge. Shneidman, E. S. (1966). Orientations towards death: A vital aspect of the study of lives. International Journal of Psychiatry, 2, 167–200. Shneidman, E. S. (1985). Definition of suicide. New York, NY: John Wiley.
Shneidman, E. S. (1993). Commentary: Suicide as psychache. Journal of Nervous and Mental Disease, 181, 145–147. Shneidman, E. S., Farberow, N. L., & Litman, R. E. (1984). The psychology of suicide: A clinician’s guide to evaluation and treatment. Northvale, NJ: Jason Aronson. Skogman, K., & Öjehagen, A. (2003). Motives for suicide: The views of the patients. Archives of Suicide Research, 7, 193–206. Stack, S., & Wasserman, I. (2007). Economic strain and suicide risk: A qualitative analysis. Suicide and Life-Threatening Behavior, 37, 103–112. Torrey, E. F., Entsminger, K., Geller, J., Stanley, J., & Jaffe, D. J. (2008). The shortage of public hospital beds for mentally ill persons. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/the_shortage_of_publichospital_beds.pdf U.S. National Bureau of Labor Statistics. (2012). The recession of 2007–2009. Retrieved from http://www.bls.gov/spotlight/2012/recession/ Williams, J. M. G. (1997). Cry of pain: Understanding suicide and self-harm. London, England: Penguin Books. Williams, J. M. G., & Pollock, L. R. (2000). The psychology of suicidal behavior. In K. Hawton & K. van Heeringen (Eds.), The international handbook of suicide and attempted suicide (pp. 79–93). West Sussex, UK: John Wiley. World Health Organization. (2014). Mental health: Suicide prevention. Retrieved from http://www.who.int/mental_health/ prevention/suicide/suicideprevent/en/
Downloaded from isp.sagepub.com at Ondokuz Mayis Universitesi on November 11, 2014
