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. Methodology/Principal Findings: 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/Significance: 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.

(NIH/NIMH) United States National Institute of Mental Health[R01MH070884]

(NIH/NIMH) United States National Institute of Mental Health[R01MH077883]

John D. and Catherine T. MacArthur Foundation

Pfizer Foundation

US Public Health Service[R13-MH066849]

US Public Health Service[R01-MH069864]

US Public Health Service[R01 DA016558]

(NIH) Fogarty International Center[FIRCA R03-TW006481]

PAHO Pan American Health Organization

Eli Lilly and Company Foundation

Ortho-McNeil Pharmaceutical, Inc.

GlaxoSmithKline

Bristol-Myers Squibb

State of Sao Paulo Research Foundation (FAPESP)[03/00204-3]

Ministry of Health

National Center for Public Health Protection

Shenzhen Bureau of Health

Shenzhen Bureau of Science, Technology, and Information

Ministry of Social Protection

European Commission[QLG5-1999-01042]

European Commission[SANCO 2004123]

Piedmont Region (Italy)

Fondo de Investigacion Sanitaria, Instituto de Salud Carlos III, Spain[FIS 00/0028]

Spanish Ministerio de Ciencia y Tecnologia[SAF 2000-158-CE]

Departament de Salut, Generalitat de Catalunya, Spain

Instituto de Salud Carlos III[CIBER CB06/02/0046]

Instituto de Salud Carlos III[RETICS RD06/0011 REM-TAP]

WHO (India)

Israel National Institute for Health Policy and Health Services Research

National Insurance Institute of Israel

Japan Ministry of Health, Labour and Welfare[H13-SHOGAI-023]

Japan Ministry of Health, Labour and Welfare[H14-TOKUBETSU-026]

Japan Ministry of Health, Labour and Welfare[H16-KOKORO-013]

Lebanese Ministry of Public Health

WHO (Lebanon)

(NIH) Fogarty International

Janssen Cilag

Eli Lilly

Roche

Novartis

National Institute of Psychiatry Ramon de la Fuente[INPRFMDIES 4280]

CNPq National Council on Science and Technology[CONACyT-G30544-H]

New Zealand Ministry of Health

Alcohol Advisory Council

Health Research Council

WHO (Geneva)

WHO (Nigeria)

Federal Ministry of Health, Abuja, Nigeria

Ministry of Public Health (former Ministry of Health)

Astrazeneca

Jazz Pharmaceuticals

Johnson Johnson

Lundbeck

Orion

Pfizer

Pharmacia

Servier

Solvay

Sumitomo

Takeda

Tikvah

Wyeth

Ortho-McNeil Pharmaceuticals

Sanofi-Aventis