Correspondence: Han-Yong Jung, M.D., Ph.D., Department of Psychiatry, Soonchunhyang University Bucheon Hospital, 1174 Jung-dong, Wonmi-gu, Bucheon, Gyeonggi-do 420-767, Korea
Tel: +82-32-621-5017, Fax: +82-32-621-5018, E-mail: hanyjung@schbc.ac.kr

Introduction

The increasing rate of suicide and suicidal attempt is a growing health problem worldwide. In 2003, the rate of suicide completers was 25.2 per 100,000 in Korea.¹ The suicide mortality rate reported in 2003 was 137% higher than that reported 10 years earlier, and suicide was the 2^nd leading cause of mortality, particularly among youths aged 15 to 19 years. The rate of suicide attempts was also found to be remarkably high: 1.01% for women and 0.82% for men.² This is an alarmingly high prevalence rate. Thus, understanding the risk factors for suicide and/or suicidal attempt is very important for mental health professionals. Suicidal behavior occurs in response to interactions between biological, psychological, and socio-environmental risk factors, along with the relative absence of protective factors.³ Most studies purporting to elicit the risk factors for suicide, for example those involving psychological autopsies, have focused on the evaluation of pathological mental status or psychiatric disorders as potential risk factors. Information about the social and environmental correlates for suicide and/or suicidal attempt is relatively scarce.⁴ There is continuing debate over the relative importance of socio-environmental risk factors as compared to psychiatric diagnostic factors in explaining suicidal behavior.⁵ However, since the identification of those with a greater risk for further attempts among the large number of people exhibiting suicidal behaviors is the most crucial aspect in such an assessment, it is necessary for mental health professionals to understand every possible risk factor.
Thus, the major purpose of this study was to investigate the psychosocial risk factors for suicide and/or suicidal attempt by reviewing the published research on the social, environmental and familial factors associated with human suicidal behaviors.

Methods

A literature search for the psychosocial risk factors of suicide and suicidal attempt was carried out using the PubMed database (http://www.ncbi.nlm.nih.gov/entrez/query. fcgi? DB = pubmed). First, a search in the Sys-temic Reviews was conducted using suicide as a search term. As a result, 408 review articles were searched. In addition, a narrow and specific search in the Clinical Study Category, limiting the language to English, and the type of article to Review, Meta-analysis, or Randomized Controlled Trial; again, the search term was suicide. As a result, 141 articles were identified. Articles in the Korean language were searched for in the KoreaMed database (http://www.koreamed.org/SearchBasic.php) using suicide as a search term. From this initial selection, the eligibility for inclusion in this review was determined by reading the abstracts of the individual articles. Relevancy to the purpose of this review was defined as the inclusion of the following descriptors or concepts: risk, risk factors, population characteristics, or prediction. Finally, 43 articles in English and 8 in the Korean language were obtained and reviewed in full text.

Results

Abuse
The articles in the literature generally support the association of adverse life events, such as physical or sexual abuse, with suicide.^{6,7,8,9,10,11} Sexual abuse, in particular, has received the most attention. The association between child sexual abuse and suicide has been clearly established in several studies.^12,13,14 In a Dutch cross-sectional study, suicide attempts were reported to be five times more common in girls and 20 times more common in boys with previous sexual abuse in comparison to non-abused adolescents.¹⁵ Furthermore, clear evidence confirming the link between child sexual abuse and suicide as a subsequent negative effect was provided in a recent meta-analysis.¹⁰ They reported a substantial effect of child sexual abuse on suicide (Glass's effect size d=.44). Child sexual abuse was associated with suicide, regardless of the victim's age, gender, or socioeconomic status, suggesting that the sexual abuse serves as a life event impacting independently on suicidal behavior.^10,16
Family violence, abuse, and neglect have been associated with suicidal behavior especially in children and adolescents.^6,17 In a prospective register based study of Danish children, adolescents who had been hospitalized and professionally assessed as a result of being battered or neglected had an increased risk of suicide attempts with an odds ratio of 10.0.¹⁸
Whether the high prevalence of suicidality is more specifically related to a history of abuse or is related to a specific consequence of various types of psychopathology or substance abuse following child abuse is not clear as yet. In the case of child sexual abuse, a multifaceted model of traumatization¹⁹ is supported rather than a specific sexual abuse syndrome leading to suicide behavior. According to this view, the impact of sexual abuse is complicated, because it produces multifaceted effects on a variety of outcomes, such as suicide, depression and post-traumatic stress disorder.

Loss
Loss event is confirmed to be a significant risk factor for suicide.²⁰ Particularly, the loss of a significant other would place the survivors in a high risk situation for suicide. Studies on bereavement have confirmed that mortality is increased in surviving spouses.²¹ People with marked dependency needs will be especially frustrated following a loss, due to the simultaneous frustration of security needs. Necessarily, parental loss due to separation, divorce, illness, or death in children or adolescents would serve as a very potent risk factor for suicide. In a study investigating parental loss as a risk factor for suicide, the suicidal patients had experienced maternal loss significantly more frequently than the non-suicidal patients.²² Moreover, the age of the patient at the death of his or her parents was revealed to be significantly lower in the suicidal group than in the non-suicidal group. A separation that reminds one of a similar event in childhood would also imply an elevated risk for suicide.
In addition to the actual loss of a significant other, threatened losses, loss of health or even the loss of a national or cultural affiliation are suggested to be associated with an increased risk for suicidal behaviors.

Family factors
Empirical research suggests that early and chronic life event stresses, particularly within the family context, are associated with suicidal behavior.^4,23,24 Various types of problems in relationships with close family members often precede suicide. A controlled study indicated that low levels of communication between parents and children may act as a significant risk factor.4 In this study, other factors such as family discord, lack of family warmth, and disturbed parent-child relationships were associated with child and adolescent psychopathology, but did not play an especially important role in suicide. A survey of 986 Korean adolescents showed dysfunctional family dynamics to be more prevalent in the suicide attempters than in the non-attempters.²⁵
A constellation of psychopathologies involving parental and sibling substance abuse, violence and antisocial personality disorder are associated with the suicide or suicide attempts of children.^6,26 It is not clear whether these family histories indicate a genetic vulnerability or environmental stressors, or a combination of these two.
More interestingly, a family history of completed suicide was found to increase the suicide risk.²⁷ Family, twin, and adoption studies consistently found that suicidal behavior aggregates in families.²⁸ Maternal suicide attempts, especially, was suggested to be one of the strongest predictors of adolescents' suicide attempts, along with other factors such as the substance abuse of fathers and family discord.²⁹ It is unclear if genetic factors play a role in mediating the familial transmission of suicide or if the observed familial clustering is caused by the effect of shared environmental factors.28 Moreover, a family history of suicidal behavior remained a significant risk factor when the effect of parental psychopathology was statistically controlled for, suggesting that the effect of family suicide history is independent of the familial clustering of psychiatric disorders.

Stressful life events
Stressful life events often precede a suicide or suicide attempt.^4,6 The occurrence of recent life events was very high, affecting up to 80% of the suicidents.³⁰ The loss of one's home, failure in studies, unemployment, financial difficulties and bankruptcy are common negative life events among people who commit suicide. The importance of these adverse life events lies in their action as a catalyst in the suicidal process.
Likewise, the association between stressful life events and suicidal behavior was reported in children. A follow up study for suicide attempts among prepubertal inpatients with suicidal ideation indicated that a high rate of stressful life events served as an important risk factor for further suicide attempts.²⁴ The authors suggested that life event stresses in the preschool years increase the risk for future suicidal behavior. Early and chronic life event stresses that lead to family instability, such as moves, death, loss of relatives, and the illness of significant caretakers are suggested to increase the likelihood for suicidal behavior among children.
Moreover, legal and disciplinary problems are found to be associated with an increased risk of suicide, even after adjusting for psychiatric disorders.³¹

Environmental influence
Suicide can be precipitated by exposure to real or fictional accounts of suicide, such as encountering news of another person's suicide and reading about a suicide portrayed in a romantic light in a book.⁶ Vulnerable teenagers are particularly at risk and it is reported that the risk lasts for approximately two weeks after the exposure.³²

Facilitating factors
Impairment in social adjustment before a suicide attempt was introduced as one of the strongest risk factors for the re-occurrence of suicidal behaviors.²⁴ Various indices of poor social adjustment were suggested to have an association with suicidal behavior in children and adolescents: dysfunctional relationships between children or adolescents and family members, poor social skills, poor leisure skills, etc.¹⁷
Factors contributing to "hopelessness", such as a negative view about one's own competence, poor self-esteem, and a sense of responsibility for negative events have been repeatedly found to be associated with suicidality.⁶ Inappropriate copying styles such as impulsivity or catastrophizing would also lead to suicidal behaviors.³³

Social integration
After examining suicide beyond the micro level, Durkheim suggested that "anomie", wherein the bond between the individual and the community is too weak, is an important factor in influencing suicide.³⁴ Living in a deprived area or single person household is generally associated with a high suicide rate. This phenomenon serves as a good example of social fragmentation as a strong predictor of suicide.³⁵ In a national register-based study of adult suicides in Korea, lower social class was found to constitute a high risk for suicide, even after controlling for variables such as age, marital status, and area of residence.³⁶

Discussion

In summary, recent or past adverse life events, such as physical and sexual abuse and loss of significant others were identified as the key risk factors for suicidal behavior. Family discord or a low level of communication and family violence are other important risk factors. Additionally, a family history of suicide has an independent effect on suicide and/or suicidal attempt along with parental psychopathology. Therefore, these familial, social, and environmental factors which imply a significant act leading to suicidal behaviors need to be routinely asked about in the assessment of suicide attempters.
Whether psychosocial risk factors act independently on suicide and/or suicide attempt is another debatable aspect. Various social and environmental factors were investigated along with familial factors or psychiatric illnesses. For example, in a comprehensive research by the Canterbury Suicide Project in New Zealand,³⁷ the authors reported the following shared circumstances associated with people who died as a result of suicide: underlying psychological distress or mental illness; recognizable mental health or adjustment difficulties before the suicide attempt; severe stress or life crisis that often centers around the breakdown of an emotional or supportive relationship; disturbed or unhappy family and childhood backgrounds; socially and educationally disadvantaged background. Recently, in a case-control psychological autopsy of 150 victims of sui-cide, the following factors were suggested to mediate suicide: unemployment, indebtedness, being single, a lack of social support, psychiatric illness, and a history of past attempts.³⁸ The authors indicated that both psychosocial and clinical factors mediate the suicide risk independently. The effect size of the psychosocial factors was suggested to be comparable with that of previously reported psychiatric disorders.^4,39
Although, no single risk factor or any combination of the above items is admitted to identify definitely or to a useful degree the future suicidal behaviors in suicide attempters,40 various risk factors may combine together to lead to suicidal behavior. For example, when a person with an active disorder (e.g., mood disorder or substance use disorder) encounters a stressful event, which is often caused by an underlying condition (loss, humiliation, trouble with law or at school, etc.), an acute mood change (anxiety, hopelessness, anger) occurs, leading to a suicidal ideation. At that point, an underlying trait (for example, impulsivity) or a lack of social support could facilitate the suicidal ideation leading to a real suicidal act.⁶
In conclusion, to understand the individual risk factors for suicide within an integrative perspective is important. Clinicians need to assess not only the interactions between the individual and family at the micro level, but also the interactions between the individual and the larger environmental context. Psychosocial risk factors, such as acute or chronic stressors, facilitators of suicide, and the background factors involved in suicide must be considered in a comprehensive context, along with the mental or pathological states and the biological vulnerability of the individual.

1. Korean Statistical Information System. Change in populations, Statistics 2004. Available from: http://kosis.nso.go.kr/.

2. Suh T. Current situation and trends of suicidal death, ideas and attempts in Korea. Korea Institute for Health and Social Affairs, 2000. Available from:http://www.kihasa.re.kr/html/jsp/main.jpg.

3. Moscicki EK. Epidemiology of completed and attempted suicide: Toward a framework for prevention. Clin Neurosc Res 2001; 1: 310-323.

4. Gould MS, Fisher P, Parides M, Flory M, Shaffer D. Psychosocial risk factors of child and adolescent completed suicide. Arch Gen Psychiatry 1996; 53: 1155-1162.

5. Adams KS. Environment, psychosocial, and psychoanalytic aspects of suicidal behavior, In: Suicide over the Life Cycle. Ed. by Blumenthal SJ, Kupfer DJ. Washington, DC, American Psychiatric Press, 1990, pp39-96.

6. AACAP Official Action. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 2001; 40 (suppl 7): 24S-51S.

7. Brown J, Cohen P, Johnson JG, Smailes EM. Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry 1999; 38: 1490-1496.

8. Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse and psychiatric disorder in young adulthood, II: psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc Psychiatry 1996; 35: 1365-1374.

9. Molnar BE, Shade SB, Kral AH, Booth RE, Watters JK. Suicidal behavior and sexual/physical abuse among street youth. Child Abuse Negl 1998; 22: 213-222.

10. Paolucci EO and Violato C. A meta-analysis of the published research on the effects of child sexual abuse. J Psychology 2001; 135 (1): 17-36.

11. Silverman AB, Reinherz HZ, Giaconia RM. The long-term sequelae of child and adolescent abuse: a longitudinal community study. Child Abuse Negl 1996; 20: 709-723.

12. Bagley C, Wood M, Young L. Victim to abuser: Mental health and behavioral sequels of child sexual abuse in a community survey of young adult males. Child Abuse Negl 1994; 18: 683-697.

13. Frazier PA and Cohen BB. Research on the sexual victimization of women: Implications for counselor training. Counseling Psychologist 1992; 20 (1): 141-158.

14. Seng MJ. Child sexual abuse and adolescent prostitution: A comparative analysis. Adolescence 1989; 24 (95): 665-675.

15. Garnefski N and Arends E. Sexual abuse and adolescent maladjustment: differences between male and female victims. J Adolesc 1998; 21 (1): 99-107.

16. Statham DJ, Heath AC, Madden PA, Bucholz KK, Bierut L, Dinwiddie SH, Slutske WS, Dunne MP, Martin NG. Suicidal behavior: an epidemiological and genetic study. Psychol Med 1998; 28: 839-855.

17. Jacobsen LK, Rabinowitz I, Popper MS, Solomon RJ, Sokol MS, Pfeffer CR. Interviewing prepubertal children about suicidal ideation and behavior. J Am Acad Child Adolesc Psychiatry 1994; 33 (4): 439-452.

18. Christoffersen MN, Poulsen HD, Nielsen A. Attempted suicide among young people: risk factors in a prospective register based study of Danish children born in 1966. Acta Psychiatr Scand 2003; 108 (5): 350-358.

19. Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychol Bull 1993; 113 (1): 164-180.

20. Cheng AT, Chen TH, Chen CC, Jenkins R. Psychosocial and psychiatric risk factors for suicide. Case-control psychological autopsy study. Br J Psychiatry 2000; 177: 360-365.

21. Schaefer C, Quesenberry CP Jr, Wi S. Mortality following conjugal bereavement and the effects of a shared environment. Am J Epidemiol 1995; 141: 1142-1152.

22. Botsis AJ, Plutchik R, Kotler M, van Praag HM. Parental loss and family violence as correlates of suicide and violence risk. Suicide Life Threat Behav 1995; 25 (2): 253-260.

23. Maris RW. Social and familial risk factors in suicidal behaviours. Psychiatr Clin North Am 1997; 20: 519-550.

24. Pfeffer CR, Klerman GL, Hurt SW, Kakuma T, Peskin JR, Siefker CA. Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up. J Am Acad Child Adolesc Psychiatry 1993; 32: 106-133.

25. Kim HS. Correlation between personality, family dynamic environment and suicidal attempt among Korean adolescents population. J Korean Acad Nursing 2002; 32 (2): 231-242.

26. Pfeffer CR, Normandin L, Kakuma T. Suicidal children grow up: suicidal behavior and psychiatric disorders among relatives. J Am Acad Child Adolesc Psychiatry 1994; 33: 1087-1097.

27. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to family history of completed suicide and psychiatric disorders: a nested case-control study based on longitudinal registers. Lancet 2002; 360 (9340): 1126-1130.

28. Pfeffer CR, Normandin L, Kakuma T. Suicidal children grow up: relations between family psychopathology and adolescents' lifetime suicidal behavior. J Nerv Ment Dis 1998; 186 (5): 269- 275.

29. Brent DA, Perper JA, Moritz G, Liotus L, Schweers J, Balach L, Roth C. Familial risk factors for adolescent suicide: A case-control study. Acta Psychiatr Scand 1994; 89: 52-58.

30. Kolves K, Varnik A, Schneider B, Fritze J, Allik J. Recent life events and suicide: A case-control study in Tallinn and Frankfurt. Soc Sci Med 2006; 62 (11): 2887-2896.

31. Brent DA, Perper JA, Moritz G, Baugher M, Roth C, Balach L, Schweers J. Stressful life events, psychopathology and adolescent suicide: a case control study. Suicide Life Threat Behav 1993; 23: 179-187.

32. Bollen KA and Phillips DP. Imitative studies: a national study of the effects of television news stories. Am Sociol Rev 1982; 47: 802-809.

33. Brent DA. The aftercare of adolescents with deliberate self-harm. J Child Psychol Psychiatry 1997; 38 (3): 277-286.

34. Durkheim E. Suicide: a study in sociology [translation by Spalding J, Simpson G]. London: Routledge and Kegan Paul, 1952.

35. Saunderson T, Haynes R, Langford IH. Urbanrural variations in suicides and undetermined deaths in England and Wales. J Pub Health Med 1998; 20: 261-267.

36. Kim MD, Hong SC, Lee SY, Kwak YS, Lee CI, Hwang SW, Shin TK, Lee SM, Shin JN. Suicide risk in relation to social class: A national register-based study of adult suicides in Korea, 1999-2001. Int J Soc Psychiatry 2006; 52 (2): 138-151.

37. Beautrais A. Suicide in New Zealand II: a review of risk factors and prevention. N Z Med J 2003; 116 (1175): U461.

38. Chen EY, Chan WS, Wong PW, Chan SS, Chan CL, Law YW, Beh PS, Chan KK, Cheng JW, Liu KY, Yip PS. Suicide in Hong Kong: a case-control psychological autopsy study. Psychol Med 2006; 36 (6): 815-825.

39. Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry 1996; 53: 339-348.

40. Pokorny AD. Suicide prediction revisited. Suicide Life Threat Behav 1993; 23: 1-10.