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The complexities of suicide: a multilevel survival analysis examining individual, familial and neighbourhood determinants of suicide risk using Danish register-based data

Published online by Cambridge University Press:  14 December 2022

Megan Davies Open the ORCID record for Megan Davies [Opens in a new window] ,
Henriette Thisted Horsdal ,
Sussie Antonsen ,
Torben Sigsgaard ,
Chun Chieh Fan ,
Wesley K. Thompson ,
Carsten Bøcker Pedersen  and
Clive E. Sabel
Megan Davies*
Affiliation:
Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark BERTHA Big Data Centre for Environment and Health, Aarhus University, Aarhus, Denmark
Henriette Thisted Horsdal
Affiliation:
BERTHA Big Data Centre for Environment and Health, Aarhus University, Aarhus, Denmark National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark
Sussie Antonsen
Affiliation:
BERTHA Big Data Centre for Environment and Health, Aarhus University, Aarhus, Denmark National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark
Torben Sigsgaard
Affiliation:
BERTHA Big Data Centre for Environment and Health, Aarhus University, Aarhus, Denmark Department of Public Health, Aarhus University, Aarhus, Denmark
Chun Chieh Fan
Affiliation:
Department of Radiology, Population Neuroscience and Genetics Lab, University of California San Diego, La Jolla, CA, USA
Wesley K. Thompson
Affiliation:
Division of Biostatistics and Department of Radiology, Population Neuroscience and Genetics Lab, University of California San Diego, La Jolla, CA, USA
Carsten Bøcker Pedersen
Affiliation:
BERTHA Big Data Centre for Environment and Health, Aarhus University, Aarhus, Denmark National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
Clive E. Sabel
Affiliation:
BERTHA Big Data Centre for Environment and Health, Aarhus University, Aarhus, Denmark Department of Public Health, Aarhus University, Aarhus, Denmark Health Research Institute, University of Canberra, Canberra, Australia
*
Author for correspondence: Megan Davies, E-mail: megan.davies@sund.ku.dk
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Abstract

Background

Suicide risk is complex and nuanced, and how place impacts suicide risk when considered alongside detailed individual risk factors remains uncertain. We aimed to examine suicide risk in Denmark with both individual and neighbourhood level risk factors.

Methods

We used Danish register-based data to identify individuals born in Denmark from 1972, with full parental information and psychiatric diagnosis history. We fitted a two-level survival model to estimate individual and neighbourhood determinants on suicide risk.

Results

We identified 1723 cases of suicide in Denmark during the follow-up period from 1982 to 2015. Suicide risk was explained mainly by individual determinants. Parental comorbidities, particularly maternal schizophrenia [incidence rate ratio (IRR): 2.29, 95% CI 1.56–3.16] and paternal death (2.29, 95% CI 1.31–3.72) partly explained suicide risk when adjusted for all other determinants. The general contextual effect of suicide risk across neighbourhoods showed a median incidence rate ratio (MRR) of 1.13 (1.01–1.28), which was further reduced with full adjustment. Suicide risk increased in neighbourhoods with a higher proportion of manual workers (IRR: 1.08; 1.03–1.14), and decreased with a higher population density (IRR: 0.89; 0.83–0.96).

Conclusion

Suicide risk varies mainly between individuals, with parental comorbidities having the largest effect on suicide risk. Suicide risk was less impacted by neighbourhood, though, albeit to a lesser extent than individual determinants, some characteristics were associated with suicide risk. Suicide prevention policies might consider targeting interventions towards individuals more vulnerable due to particular parental comorbidities, whilst taking into account that some neighbourhood characteristics might exacerbate this risk further.

Keywords

Health registersMultilevel modellingSuicideSurvival analysis
Type
Original Article
Information
Psychological Medicine , Volume 53 , Issue 13 , October 2023 , pp. 6356 - 6365
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Copyright
Copyright © The Author(s), 2022. Published by Cambridge University Press

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References

Andrés, A. R., Collings, S., & Qin, P. (2010). Sex-specific impact of socio-economic factors on suicide risk: A population-based case–control study in Denmark. European Journal of Public Health, 20(3), 265–270. doi: 10.1093/eurpub/ckp183CrossRefGoogle Scholar
Andrés, A. R., & Halicioglu, F. (2010). Determinants of suicides in Denmark: Evidence from time series data. Health Policy, 98(2–3), 263–269. doi: 10.1016/j.healthpol.2010.06.023CrossRefGoogle ScholarPubMed
Austin, P. C., Stryhn, H., Leckie, G., & Merlo, J. (2018). Measures of clustering and heterogeneity in multilevel Poisson regression analyses of rates/count data. Statistics in Medicine, 37(4), 572–589. doi: 10.1002/sim.7532CrossRefGoogle ScholarPubMed
Bilsker, D., & White, J. (2011). The silent epidemic of male suicide. British Columbia Medical Journal, 53(10), 529–534. Retrieved from https://bcmj.org/.Google Scholar
Björkenstam, C., Kosidou, K., & Björkenstam, E. (2017). Childhood adversity and risk of suicide: Cohort study of 548 721 adolescents and young adults in Sweden. BMJ, 357, j1334. doi: 10.1136/BMJ.J1334CrossRefGoogle Scholar
Caqueo-Urízar, A., Rus-Calafell, M., Craig, T. K. J., Irarrazaval, M., Urzúa, A., Boyer, L., … Williams, D. R. (2017). Schizophrenia: Impact on family dynamics. Current Psychiatry Reports, 19(2). doi: 10.1007/s11920-017-0756-zCrossRefGoogle ScholarPubMed
Cassidy, F. (2011). Risk factors of attempted suicide in bipolar disorder. Suicide and Life-Threatening Behavior, 41(1), 6–11. doi: 10.1111/j.1943-278X.2010.00007.xCrossRefGoogle ScholarPubMed
Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40(5), 373–383. doi: 10.1016/0021-9681(87)90171-8CrossRefGoogle ScholarPubMed
Congdon, P. (2013). Assessing the impact of socioeconomic variables on small area variations in suicide outcomes in England. International Journal of Environmental Research and Public Health, 10(1), 158–177. doi: 10.3390/ijerph10010158CrossRefGoogle Scholar
Duncan, C., Jones, K., & Moon, G. (1993). Do places matter? A multi-level analysis of regional variations in health-related behaviour in Britain. Social Science and Medicine, 37(6), 725–733. doi: 10.1016/0277-9536(93)90366-CCrossRefGoogle Scholar
Fone, D., White, J., Farewell, D., Kelly, M., John, G., Lloyd, K., … Dunstan, F. (2014). Effect of neighbourhood deprivation and social cohesion on mental health inequality: A multilevel population-based longitudinal study. Psychological Medicine, 44, 2449–2460. doi: 10.1017/S0033291713003255CrossRefGoogle ScholarPubMed
Geulayov, G., Gunnell, D., Holmen, T. L., & Metcalfe, C. (2012). The association of parental fatal and non-fatal suicidal behaviour with offspring suicidal behaviour and depression: A systematic review and meta-analysis. Psychological Medicine, 42(8), 1567–1580. doi: 10.1017/S0033291711002753CrossRefGoogle ScholarPubMed
Goodwin, R. D., Beautrais, A. L., & Fergusson, D. M. (2004). Familial transmission of suicidal ideation and suicide attempts: Evidence from a general population sample. Psychiatry Research, 126(2), 159–165. doi: 10.1016/j.psychres.2004.02.010CrossRefGoogle ScholarPubMed
Guldin, M. B., Li, J., Pedersen, H. S., Obel, C., Agerbo, E., Gissler, M., … Vestergaard, M. (2015). Incidence of suicide among persons who had a parent who died during their childhood a population-based cohort study. JAMA Psychiatry, 72(12), 1227–1234. doi: 10.1001/jamapsychiatry.2015.2094CrossRefGoogle ScholarPubMed
Hagedoorn, P., Groenewegen, P. P., Roberts, H., & Helbich, M. (2020). Is suicide mortality associated with neighbourhood social fragmentation and deprivation? A Dutch register-based case–control study using individualised neighbourhoods. Journal of Epidemiology and Community Health, 74(2), 197–202. doi: 10.1136/jech-2019-212699CrossRefGoogle ScholarPubMed
Helweg-Larsen, K. (2011). The Danish register of causes of death. Scandinavian Journal of Public Health, 39(7), 26–29. doi: 10.1177/1403494811399958CrossRefGoogle ScholarPubMed
Hirsch, J. K., & Cukrowicz, K. C. (2014). Suicide in rural areas: An updated review of the literature. Journal of Rural Mental Health, 38(2), 65–78. doi: 10.1037/rmh0000018CrossRefGoogle Scholar
Jakobsen, A. L., & Lund, R. L. (2022). Neighborhood social context and suicide mortality: A multilevel register-based 5-year follow-up study of 2.7 million individuals. Social Science and Medicine, 311, 115320. doi: 10.1016/j.socscimed.2022.115320CrossRefGoogle ScholarPubMed
Jensen, V. M., & Rasmussen, A. W. (2011). Danish education registers. Scandinavian Journal of Public Health, 39(7), 91–94. doi: 10.1177/1403494810394715CrossRefGoogle ScholarPubMed
Kanamori, M., Kondo, N., Juarez, S., Dunlavy, A., Cederström, A., & Rostila, M. (2020). Rural life and suicide: Does the effect of the community context vary by country of birth? A Swedish registry-based multilevel cohort study. Social Science and Medicine, 253, 112958. doi: 10.1016/j.socscimed.2020.112958CrossRefGoogle ScholarPubMed
Lynge, E., Sandegaard, J. L., & Rebolj, M. (2011). The danish national patient register. Scandinavian Journal of Public Health, 39(7), 30–33. doi: 10.1177/1403494811401482CrossRefGoogle ScholarPubMed
Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365(9464), 1099–1104. doi: 10.1016/S0140-6736(05)71146-6CrossRefGoogle ScholarPubMed
Marmot, M. (2009). Health equity in England: the Marmot review 10 years on Ten years after the landmark review on health inequalities in England, coauthor Michael Marmot says the situation has become worse. doi: 10.1136/bmj.m693CrossRefGoogle Scholar
Merlo, J., Wagner, P., Austin, P. C., Subramanian, S. V, & Leckie, G. (2018). General and specific contextual effects in multilevel regression analyses and their paradoxical relationship: A conceptual tutorial. SSM-Population Health, 5, 33–37. doi: 10.1016/j.ssmph.2018.05.006CrossRefGoogle ScholarPubMed
Monroe, S. M., Slavich, G. M., & Gotlib, I. H. (2014). Life stress and family history for depression: The moderating role ofpast depressive episodes. Journal of Psychiatric Research, 49(1), 90–95. doi: 10.1016/j.jpsychires.2013.11.005CrossRefGoogle ScholarPubMed
Mors, O., Perto, G. P., & Mortensen, P. B. (2011). The Danish psychiatric central research register. Scandinavian Journal of Public Health, 39(7), 54–57. doi: 10.1177/1403494810395825CrossRefGoogle ScholarPubMed
Mortensen, P. B., Pedersen, M. G., & Pedersen, C. B. (2010). Psychiatric family history and schizophrenia risk in Denmark: Which mental disorders are relevant? Psychological Medicine, 40(2), 201–210. doi: 10.1017/S0033291709990419CrossRefGoogle ScholarPubMed
Naghavi, M. (2019). Global, regional, and national burden of suicide mortality 1990 to 2016: Systematic analysis for the global burden of disease study 2016. BMJ (Clinical Research Ed.), 364, l94. doi: 10.1136/bmj.l94Google ScholarPubMed
Neeleman, J., & Wessely, S. (1999). Ethnic minority suicide: A small area geographical study in south London. Psychological Medicine, 29(2), 429–436. doi: 10.1017/S003329179800806XCrossRefGoogle ScholarPubMed
Ngamini Ngui, A., Vasiliadis, H. M., & Préville, M. (2015). Individual and area-level factors correlated with death by suicide in older adults. Preventive Medicine, 75, 44–48. doi: 10.1016/j.ypmed.2015.03.015CrossRefGoogle ScholarPubMed
Nordentoft, M., Mortensen, P. B., & Pedersen, C. B. (2011). Absolute risk of suicide after first hospital contact in mental disorder. Archives of General Psychiatry, 68(10), 1058–1064. doi: 10.1001/ARCHGENPSYCHIATRY.2011.113CrossRefGoogle ScholarPubMed
O'farrell, I. B., Corcoran, P., & Perry, I. J. (2016). The area level association between suicide, deprivation, social fragmentation and population density in the Republic of Ireland: A national study. Social Psychiatry and Psychiatric Epidemiology, 51, 839–847. doi: 10.1007/s00127-016-1205-8CrossRefGoogle Scholar
Palmer, M. N. (2020). Accuracy of Death Certificate Data in Reporting Suicide in the Accuracy of Death Certificate Data in Reporting Suicide in the United States United States. Walden University. Retrieved from https://scholarworks.waldenu.edu/dissertations.Google Scholar
Pedersen, C. B. (2011). The Danish civil registration system. Scandinavian Journal of Public Health, 39(7), 22–25. doi: 10.1177/1403494810387965CrossRefGoogle ScholarPubMed
Pedersen, C. B., Antonsen, S., Timmermann, A., Pedersen, M. G., Ejlskov, L., Horsdal, H. T., … Thompson, W. K. (2022). Urban-rural differences in schizophrenia risk: Multilevel survival analyses of individual- and neighborhood-level indicators, urbanicity and population density in a Danish national cohort study. Schizophrenia Bulletin Open, 3(1), 1–12. doi: 10.1093/schizbullopen/sgab056CrossRefGoogle Scholar
Petersson, F., Baadsgaard, M., & Thygesen, L. C. (2011). Danish registers on personal labour market affiliation. Scandinavian Journal of Public Health, 39(7), 95–98. doi: 10.1177/1403494811408483CrossRefGoogle ScholarPubMed
Pitman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on mental health and suicide risk. The Lancet Psychiatry, 1(1), 86–94. doi: 10.1016/S2215-0366(14)70224-XCrossRefGoogle ScholarPubMed
Pompili, M., Amador, X. F., Girardi, P., Harkavy-Friedman, J., Harrow, M., Kaplan, K., … Tatarelli, R. (2007). Suicide risk in schizophrenia: Learning from the past to change the future. Annals of General Psychiatry, 6(1), 1–22. doi: 10.1186/1744-859X-6-10/TABLES/1CrossRefGoogle ScholarPubMed
Rezaeian, M., Dunn, G., St Leger, S., & Appleby, L. (2005). The ecological association between suicide rates and indices of deprivation in English local authorities. Social Psychiatry and Psychiatric Epidemiology, 40(10), 785–791. doi: 10.1007/s00127-005-0960-xCrossRefGoogle ScholarPubMed
Ringgenberg, W., Peek-Asa, C., Donham, K., & Ramirez, M. (2018). Trends and characteristics of occupational suicide and homicide in farmers and agriculture workers, 1992-2010 HHS public access. The Journal of Rural Health, 34(3), 246–253. doi: 10.1111/jrh.12245CrossRefGoogle Scholar
Rod, N. H., Bengtsson, J., Budtz-Jørgensen, E., Clipet-Jensen, C., Taylor-Robinson, D., Andersen, A.-M. N., … Rieckmann, A. (2020). Trajectories of childhood adversity and mortality in early adulthood: A population-based cohort study. The Lancet, 396, 489–497. doi: 10.1016/S0140-6736(20)30621-8CrossRefGoogle ScholarPubMed
Stenager, K., & Qin, P. (2008). Individual and parental psychiatric history and risk for suicide among adolescents and young adults in Denmark A population-based study. Social Psychiatry and Psychiatric Epidemiology, 43, 920–926. doi: 10.1007/s00127-008-0385-2CrossRefGoogle Scholar
Tidemalm, D., Runeson, B., Waern, M., Frisell, T., Carlström, E., Lichtenstein, P., & Längström, N. (2011). Familial clustering of suicide risk: A total population study of 11.4 million individuals. Psychological Medicine, 41(12), 2527–2534. doi: 10.1017/S0033291711000833CrossRefGoogle Scholar
Titelman, D., Oskarsson, H., Wahlbeck, K., Nordentoft, M., Mehlum, L., Jiang, G. X., … Wasserman, D. (2013). Suicide mortality trends in the Nordic countries 1980-2009. Nordic Journal of Psychiatry, 67(6), 414–423. doi: 10.3109/08039488.2012.752036CrossRefGoogle ScholarPubMed
Tøllefsen, I. M., Hem, E., & Ekeberg, Ø. (2012). The reliability of suicide statistics: A systematic review. BMC Psychiatry, 12(1), 1–11. doi: 10.1186/1471-244X-12-9/TABLES/3CrossRefGoogle ScholarPubMed
Vassos, E., Agerbo, E., Mors, O., & Pedersen, C. B. (2016). Urban-rural differences in incidence rates of psychiatric disorders in Denmark. The British Journal of Psychiatry, 208, 435–440. doi: 10.1192/bjp.bp.114.161091CrossRefGoogle ScholarPubMed
Vichi, M., Vitiello, B., Ghirini, S., & Pompili, M. (2020). Does population density moderate suicide risk? An Italian population study over the last 30 years. European Psychiatry, 63(1), 1–7. doi: 10.1192/j.eurpsy.2020.69CrossRefGoogle ScholarPubMed
Von Borczyskowski, A., Lindblad, F., Vinnerljung, B., & Hjern, A. (2010). Gender differences in risk factors for suicide: Findings from a Swedish national cohort study. Canadian Journal of Psychiatry, 55(2), 108–111. doi: 10.1177/070674371005500207CrossRefGoogle ScholarPubMed
Webb, R. T., Pedersen, C. B., & Mok, P. L. H. (2016). Adverse outcomes to early middle age linked with childhood residential mobility. American Journal of Preventive Medicine, 51(3), 291–300. doi: 10.1016/j.amepre.2016.04.011CrossRefGoogle ScholarPubMed
Whitley, R. (2021). The social determinants of male suicide. In Men's issues and men's mental health: An introductory primer (pp. 23–43). Cham: Springer International Publishing. doi: 10.1007/978-3-030-86320-3_2CrossRefGoogle Scholar
Wilkinson, P. O., Harris, C., Kelvin, R., Dubicka, B., & Goodyer, I. M. (2013). Associations between adolescent depression and parental mental health, before and after treatment of adolescent depression. European Child and Adolescent Psychiatry, 22(1), 3–11. doi: 10.1007/s00787-012-0310-9CrossRefGoogle ScholarPubMed
World Health Organization. (2021). Comprehensive mental health action plan 2013–2030. Geneva: World Health Organization.Google Scholar
Zammit, S., Gunnell, D., Lewis, G., Leckie, G., Dalman, C., & Allebeck, P. (2014). Individual- and area-level influence on suicide risk: A multilevel longitudinal study of Swedish schoolchildren. Psychological Medicine, 44(2), 267–277. doi: 10.1017/S0033291713000743CrossRefGoogle Scholar
Zammit, S., Lewis, G., Rasbash, J., Dalman, C., Gustafsson, J.-E., & Allebeck, P. (2010). Individuals, schools, and neighborhood A multilevel longitudinal study of variation in incidence of psychotic disorders. Archives of General Psychiatry, 67(9), 914–922. doi: 10.1001/archgenpsychiatry.2010.101CrossRefGoogle ScholarPubMed
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