Risk factors for suicide in Bali: a psychological autopsy study

Suicide is one of the major causes of death worldwide [1]. In Bali, Suryani et al. [2] demonstrated that the suicide rate in the period following the 2002 Bali bombings was 8.10 for males and 3.68 for females per 100,000 population. Following the bombings, suicide rates increased nearly four-fold in males and three-fold in females [2]. Although the suicide rate is lower than the world average, these results suggest that suicide should be recognized as a major health problem in Bali. Given that this figure is probably underestimated due to underreporting of suicides, the actual impact of suicide on mortality in Bali is most likely much higher. Furthermore, as the Balinese Hindu religion considers suicide to be an offense against the gods that leads to punishment in the next life [3], suicide is a major social concern in Bali.

To our knowledge, no study has been conducted in Bali examining risk factors for suicide. Although studies from other Asian countries have demonstrated that risk factors for suicide are similar to those in western countries [4‐12], culturally or socially unique findings are also noted in each study. For instance, Phillips et al. [6] showed that the presence of a psychiatric disorder was not a significant predictor of suicide in the final regression model in China, although a substantial amount of published work from western countries has reported a link between psychiatric disorders and suicidal behaviors. Moreover, Chen et al. [9] demonstrated that socio-economic adversities such as unemployment and debt have played an important role in suicide in Hong Kong during the recent economic recession. Therefore, in order to establish a culturally appropriate suicide prevention program, it is essential to investigate the risk factors of suicide particular to each region. The psychological autopsy method, which is based on interviews with informants close to the deceased, is currently the most direct technique to examine the relationship between specific factors and suicide [13].

The aim of the present study is to examine socio-demographic, clinical, and psychosocial correlates for suicide in Bali using a case-control psychological autopsy approach. This is the first study to investigate risk factors for suicide in Bali.

In the present study, a wide range of psychosocial and clinical factors that may be related to suicide in Bali were examined. This is the first successful psychological autopsy study in this developing country setting with a high participation rate for both suicide cases and controls, face-to-face direct interviews with key informants, and all informants consisting of close relatives rather than non-family members such as friends and visiting nurses. The results indicated that risk factors for suicide include at least one psychiatric diagnosis, a low level of religious involvement, and severe interpersonal problems.

Mental disorder was the most influential risk factor for suicide in Bali. Robins et al. [20] found that 93% of 109 patients brought to a general hospital immediately after a suicide attempt suffered from psychiatric disorders. According to a systematic review of psychological autopsy studies of suicide [13], mental disorder was the most strongly associated variable of those that had been studied, and the median proportion of cases of mental disorder was 90% (range: 86 - 97%). The results of the present study are therefore consistent with previous psychological autopsy studies, although the percentage of mental disorders in this study was slightly lower (80%) than previously reported. Major depression was the most common diagnosis (51.7%) among suicide cases with mental disorders. This finding is consistent with those from other psychological autopsy studies [13]. On the other hand, alcohol abuse, another predominant mental disorder, was observed in only four suicide cases (6.7%). This finding is not consistent with most other studies except for one study from Pakistan [11], an Islamic country where alcohol is legally banned. Although alcohol is not prohibited by Balinese Hinduism, alcoholism is very rare in Bali, as drinking may cause one to lose his or her sense of geological orientation (e.g., the direction of the holy mountain of Gunung Agung, which represents the positive forces of universe) [21]. Economic factors or the Balinese people's aversion to losing control of their emotions may also contribute to the low prevalence of alcoholism in Bali.

A low level of religious involvement was also found to be a significant risk factor for suicide in Bali. Previous studies in developed countries revealed that religious participation decreases the risk of both suicide completion [22, 23] and suicide attempts [24, 25]. Possible causes for this effect include the broader social network and increased instrumental support provided by frequent religious participation [24, 26]. In Bali, religious ceremonies integrate individuals into the society and provide a forum for the exchange of informational, emotional and tangible social support among community members. In addition, as many religions--including Balinese Hinduism--strongly prohibit suicide, it follows that adherence to these religious doctrines would make followers less likely to attempt suicide [24, 26]. Therefore, both social support and religious doctrine appear to contribute to the relationship between religious activities and suicide. The results of the present study showed that religion remained a significant item in the final multiple regression model, while social support items (i.e., size of social network and frequency of social contact) did not; however, it is premature to conclude that religion has a stronger effect on suicide than social support, as the social support items used in this study were not comprehensive. Further examination is needed to explore the relationship between religious involvement and suicide in Bali using more detailed social support criteria. To our knowledge, this is the first psychological autopsy study in an Asian developing country to indicate a significant association between religious activities and suicide completion.

Severe interpersonal problems were also identified as a risk factor for suicide in the present study. This finding is similar to those from Western countries [27‐29] and Asian countries [6, 8, 10]. Interpersonal problems were more directly related to suicide than other negative life events, such as financial problems, in this study. In general, Balinese live in communities with high population densities where frequent community activities create complicated interactions among families and community members. In such a social setting, severe interpersonal problems may reach a critical point and make an individual more likely to attempt suicide.

The present study revealed several important implications for suicide prevention in Bali. The strongest risk factor for suicide identified in the present study was mental disorder--48 (80.0%) suicide cases were diagnosed with mental disorders. However, only 16.7% of these cases contacted a primary health care professional, and none had received any psychiatric treatment during the 1 month prior to death. This finding is contrary to results from developed countries, where a majority of suicide cases had visited a primary care physician during the 1 month before death [30, 31]. In Bali, public education aimed at fostering help-seeking behaviors in individuals with mental disorders is essential for suicide prevention. In addition, education programs for primary care health professionals on the recognition and management of mental disorders are important, and the accessibility and availability of mental health care in Bali must be improved. However, Chen and Yip [32] point out that increasing the number of psychiatric professionals may not directly translate into a decrease in suicide rate, as the suicide rate in Taiwan has increased three-fold in the past decade despite a 100% increase in the number of psychiatrists. They argue that a community-based method, rather than a psychiatric or clinical approach, is more relevant and cost-effective in Asian countries. Although the treatment of mental disorders in Bali is essential, such community-based prevention strategies also appear to be important. In the present study, a low level of religious activities and severe interpersonal relationship problems were also identified as significant risk factors. For the former, community-based intervention by religious leaders may be beneficial, while for the latter, consultation with either community leaders or traditional healers may be effective. For instance, religious leaders may be able to inquire about the absence of withdrawn individuals from religious ceremonies and offer the individuals or their families a religious solution, and community leaders could function as mediators of interpersonal conflicts within the community. Through those processes, religious and community leaders may be able to develop and reinforce social networks to support individuals at risk of committing suicide.

The present study has several limitations. First, the methodological problems inherent to psychological autopsy studies should be noted--the interviewer was not blind to suicide/control status, and the long duration between time of death and interview may have caused recall bias on the part of the informants. However, in the present study, a careful consensus meeting was held for the coding process of each factor in an attempt to minimize bias. Second, the present study's small sample size makes the interpretation of the results rather difficult. Third, data extracted from police reports may be a major source of bias due to the underreporting of suicides.

In summary, the present study identified at least one psychiatric diagnosis, a low level of religious involvement, and severe interpersonal problems as risk factors for suicide in Bali. Both clinical and community-based suicide prevention strategies are essential. Future studies should evaluate which aspects of prevention strategies are effective for establishing the most relevant suicide prevention program in Bali.