by Michael D. Anestis, M.S.
Right now, I'm approximately two-thirds of the way through the portion of my Abnormal Psychology course during which I teach my students about suicide. As I have mentioned on PBB many times before, suicide is topic plagued by misinformation and, as a result, I spend a good portion of this lecture discussing specific studies that refute commonly held but mistaken beliefs about suicide (e.g., suicide is an impulsive behavior, assessing for suicide risk causes people to become suicidal). In today's lecture, I spent a bit of time talking with my students about the fact that religious and cultural beliefs that discourage suicide are considered by many to be a protective factor, meaning that maintaining such beliefs indicates a lower risk that an individual will attempt and die by suicide. As we talked about this, I cautioned them not to leap to conclusions about the meaning of that data, as other factors often better explain the relationship between two variables.
Today, I would like to describe a study conducted by Randall Richardson-Vejlgaard and colleagues at the Columbia University College of Physicians and Surgeons and the Columbia University School of Social Work that was published in late 2009 in the Journal of Affective Disorders. In this study, the authors looked at view of suicide in depressed individuals with and without alcohol use disorders (AUDs). Their goal was essentially to see if those with AUDs maintained different views towards suicide than individuals without AUDs and whether those views were related to suicidal ideation and behavior.
To do this, this authors recruited a sample of 521 participants diagnosed with depression (73% of sample) or bipolar disorder (currently in the depression phase; 27% of sample) as determined through a structured diagnostic interview. 42% of the sample reported a past history of AUD and 50% had attempted suicide in the past. 60% of the sample with a history of AUDs had a previous suicide attempt compared to 42% of the non-AUD sample.
The key finding in this study, as indicated by the authors, was that individuals with AUDs had fewer moral objections to suicide than did individuals without AUDs. Additionally, a lack of moral objections to suicide was associated with higher levels of suicidal ideation and prior suicidal behavior. The authors were careful not to overstate the implications of their findings, but the general assumption was that the lack of moral objections facilitates suicidal behavior in individuals with AUDs. Certainly this viewpoint is worthy of consideration; however, I found myself a bit frustrated by the data and conclusions here.
In order to determine whether or not one variable explains the relationship between two others (statistical mediation), there are very specific procedures that can be conducted. In this case, to test whether having fewer moral objections to suicide explains why individuals with AUDs report more lifetime suicide attempts, the authors simply needed to run a specific analytical procedure; however, this test was not run. Because of this, we can see that these variables are related, but we can not tell whether or not one explains any of the others. In this situation, we are left to simply make educated guesses, which is a dangerous game when we are discussing suicide, as so many misguided beliefs are so prominent. Given that the individuals in this sample with AUDs had a higher rate of bipolar disorder relative to those without AUDs, it is entirely possible that the greater degree of severe mental illness accounted for all of these findings. The authors did not control for diagnostic status, however, so we can not know for certain whether or not that is the case.
Let me explain what I mean with these issues more directly. One interpretation of the data here is that depressed individuals with AUDs report greater levels of suicidal ideation and behavior because they have fewer moral objections to the behavior and, as such, have fewer reasons to choose alternative options. Another interpretation, however, is that moral obligations to the behavior fade as the behavior itself occurs, and that individuals may have changed their views (and started drinking) after they made an attempt. In other words, it would be difficult to find a sample of individuals who have repeatedly engaged in a behavior and admitted to that who also report that they are morally against it. As such, "moral objections" could simply represent an untested theory on the part of individuals who have not yet been faced with that situation and lower objections could simply be a way for individuals to adapt their viewpoints to be more consistent with their reality.
Yet another interpretation, and one I tend to favor, is that moral objections to suicide (particularly when measured using the specific scale used in this study) tend to be a proxy measure for religiosity. As we discussed in an earlier PBB article (click here to read the article), data indicate that the reason religiosity and its associated beliefs are protective against suicidal behavior is that the individuals who tend to maintain such beliefs also tend to be a part of a tight nit community. When individuals maintain highly religious beliefs but do so only in private (e.g., through private prayers or meditation), they are no less likely to think about suicide or to engage in suicidal behavior than are individuals without such beliefs; however, when individuals with high levels of religiosity engage in public worship (e.g., regularly attend church services), they are, in fact, protected. Such data - and there is much, much more to that study - indicate that it is not the beliefs themselves that impact the behavior, but rather the social support inherent in being a part of a community. Taking it a step further, in another prior PBB article (click here to read the article), I detailed data that indicates that individuals who tend to drink heavily while alone are more prone to suicidal ideation and that individuals who engage in solitary heavy drinking tend to do so in an effort to cope with negative emotions. So, if individuals with AUDs tend to have fewer moral objections to suicide, this might actually represent a tendency to be less active with respect to public worship. As such, they be more inclined to become isolated and to drink alone (as they do not have social support to help them deal with negative emotions), which is also associated with suicidal ideation.
My point here is not to dismiss the findings of Richardson-Vejlgaard and colleagues (2009), but rather to point out that, when we think about suicide and the risk factors that contribute to such behaviors, we have to be careful not to leap to conclusions. Richardson-Vejlgaard et al (2009), in fact, did not jump to conclusions. They were very modest in their interpretation of the data, but the study nonetheless represents a good teaching point in data analysis and suicide. Much like the link between impulsivity and suicide is indirect (e.g., suicide itself is not an impulsive behavior, but impulsive people are more likely to attempt and die by suicide), moral objections to suicide might be only indirectly related to suicidal outcomes (e.g., moral objections indicate membership in a tight nit religious community, which offers social support, which lowers suicide risk). If we overlook that point and assume the link is direct, we can lose sight of the importance of social support, overstate the importance of viewing suicide in a particular manner, and ultimately further stigmatize individuals who attempt and die by suicide (or even those who devote their lives to preventing suicide but do not see it as a sin or a sign of weakness). Ultimately, what matters here are the facts, and the data thus far seem to indicate that we need to consider the role of religion in suicide a bit differently than many have in the past.
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If you or anyone you know are experiencing thoughts of suicide, we encourage you to call 1-800-273-TALK or to find somebody to take you to the emergency room.
If you would like to learn more about suicide, we encourage you to read the following items, each of which is available through our online store for scientifically-based psychological resources:
- Why People Die by Suicide
by Thomas Joiner
- The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
- Treating Suicidal Behavior: An Effective, Time-Limited Approach
by David Rudd, Thomas Joiner, and Hasan Rajab
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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