It has been estimated that worldwide
almost a million persons commit suicide
every year.1 In the United States, the
annual suicide rate is approximately 12
per 100,000.2 In Europe, the suicide rate
ranges from approximately 4 per
100,000 (Greece, Italy, Spain) to 40 per
100,000 (Hungary, Finland, Sweden).3
Intermediate suicide rates such as 22
per 100,000 have been reported in other
nations (eg, China).4 The most common
immediate risk factors for suicide are
mental disorders, particularly mood and
substance use disorders. Almost 90%
of suicide attempts take place among
persons with a current mental disorder;
and approximately 80% of these persons
do not receive treatment before attempting
suicide.5,6 Other suicide risk factors
include chronic pain or psychiatric
disorder of one's partner.7,8
Suicide rates increased in many parts
of the world from 1970 to 1990, followed
by a plateau or a slight decrease
in recent years.9,10 Suicide is relatively rare among children younger than 10
years (0.05 cases per 100,000). In early
adolescence (10 to 14 years), there is
a 30-fold increase in risk (approximately
1.5 cases per 100,000). Among
15- to 24-year-olds, an additional 10-
fold rise in risk has been observed (13
cases per 100,000).11 Although women
report more suicide attempts and
suicidal ideation, men have the highest
rate of completed suicide.12,13
Epidemiology of severe
Documented cases of childhood physical
abuse, sexual abuse, and neglect
are relatively common in the general
population (approximately 12 victims
per 1000 children). In 2004, an estimated
872,000 children were found to
be victims of childhood abuse or neglect
in the United States.14 Because many
cases of abuse and neglect are not
reported to authorities, the actual frequency
of childhood maltreatment is
likely to be substantially higher.15
Physical punishment during childhood
is common (approximately 60% of
adults in the United States report having
experienced corporal punishment in childhood). More severe acts of physical
violence and victimization during
childhood (eg, being struck with objects)
were reported by 11% of adults in 1985;
the prevalence of childhood physical
abuse was estimated to be 1.9% in
The prevalence of sexual abuse was
investigated in a recent meta-analysis
of 168 studies including almost 1 million
persons.16 Worldwide, about 5% of
women and 3% of men reported having
been sexually abused during childhood
(intercourse or anal/oral contact). An
additional 13% of women and 3% of
men reported less severe incidents of
sexual activity (unwanted physical
contact without intercourse or anal/oral
contact). Moreover, 7% of women and
3% of men reported incidents of childhood
sexual abuse without physical
contact, such as exhibitionism.
adversities associated with
risk for suicidal behavior
Numerous studies have investigated the
associations of specific childhood adversities
with suicide risk. These adversities
include childhood maltreatment, problematic
family relationships, socioeconomic
hardship, and difficult
relationships with peers (Table).17-28
Childhood physical and sexual abuse
have been found to be particularly important
risk factors in retrospective29-30
and prospective studies31,32 in populations
of young adults20 and older adults.33
Problematic family relationships, including
certain combinations of
maladaptive parental behaviors (eg, affectionless
or overprotective parenting),
have been reported to be associated with
risk for suicide.34-36
Other risk factors include a history
of mental disorders,9 parental psychopathology,37 a family history of suicidal
behavior,17 and parental financial hardship
or unemployment.21 Suicidal behavior
is known to be multidetermined, with
many risk factors playing important
contributory roles.9,21,38 For example,
one study showed that of 70 risk factors
investigated in bivariate analyses, more
than 50 were significantly associated
with suicidal ideation or deliberate selfharm.
39 In addition, persons who have
experienced a series of adversities
during childhood and adolescence have
been found to be at particularly elevated
risk for suicide.35,40
Several studies have examined a variety
of risk factors and their differential
contributions to later suicide risk. Studies
using cumulative adversity indices have
indicated that the predictive power for
single adversities was lower than for the
combined effects of multiple risk
factors.29,38 The underlying rationale of
the use of summation indices is that most
persons are resilient enough to cope with a certain amount of adversity, but if
adversities rise above this threshold,
coping abilities fail and risk for suicidal
behavior increases.21,41 When extreme
groups are compared, this can result in
extraordinarily large effect sizes. For example, Felitti and associates29 found
that there was a 25-fold increase in the
probability of reporting a suicide attempt
by persons who reported numerous
childhood adversities compared with
persons who reported only one risk
factor or none at all.42
Childhood adversity factors associated
with elevated risk for suicidal behavior
Childhood maltreatment or victimization
Problematic parenting or family environment
Other childhood adversities
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