In Australia, more than 2000 people die by suicide each year and it is the most common cause of death for men and women under 44 years of age. The causes of suicide are often multifactorial and associations are seen with predisposing factors including mental illness, drug and alcohol issues, regional location, ethnicity and race and the presence of domestic violence. In many cases, people who suicide may have more than a single risk factor, making it difficult to determine causality.
MacIsaac et al1 reported a systematic review of the relationship between interpersonal violence (IPV) and suicide in both men and women as both perpetrators and victims. The authors searched eight medical, social science, public health and criminology databases, including Medline, PsycINFO, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Library and Criminal Justice Abstracts. Databases were searched from their inception to March 2015. Search terms used encompassed a wide range of descriptors of self harm and suicide, physical and sexual violence, death and injury. After search and elimination of duplicates and examination of the 5216 titles and abstracts and 320 full-text articles, a final 38 articles were included in the analysis. The included articles were published between 1981 and 2014 and 18 studies included only women. Study types included retrospective record audits, cohort studies, psychological autopsy and two articles reviewing media reports.
Thirty-six of the studies reported on the strength of the relationship between being the victim of interpersonal violence and death by suicide. The reported lifetime prevalence of exposure to violence in women dying from suicide ranged from 3.5 per cent to 62.5 per cent. Alternatively, two studies reported that being the victim of violence conferred a 17–40-fold increase in risk of death by suicide. These results were not consistent across all studies. One study showed that after controlling for confounders such as mental illness, there was no significant relationship between interpersonal violence and death by suicide. In that study, 85 per cent of women dying of suicide with a history of domestic violence also had a history of depression or other mental illness. This association between violence, mental illness and suicide highlights the difficulty in determining causality.
As this review considered studies from across the world there were a number of studies in which suicide and domestic violence had specific cultural contexts. In countries with a dowry system, such as India, Pakistan, Bangladesh and Iran, if the requirements for the dowry are not met by the bride’s family the husband’s family may subject the woman to physical and mental abuse. In this case, some women may see suicide as their only means of escape. Such cultural considerations are relevant in other countries, especially with consideration of violence in immigrant communities.
As the authors state, at the time of writing, theirs was the only systematic review of IPV and suicide among women. Despite this, they acknowledge its limitations. The study had very broad inclusion criteria in terms of the search terms, geographical location, inclusion of studies of perpetrators of violence and no limitations on type of study methodology. Limitations were that only English language studies were included and that the authors excluded some studies where gender was not reported. They also excluded studies of murder-suicide. While these cases may almost always include evidence of domestic violence, the authors decided that they were more likely to accurately involve the psychology of homicide rather than suicide and that the perpetrators were generally men, rather than women, who were the focus of this study.
In conclusion, this review highlights the difficulties in studying the relationship between domestic violence and suicide, but finds there is definitely an association between domestic violence and suicide in women. In many cases this association may be mediated via mechanisms such as mental illness and depression, social isolation or cultural practices. While this makes research more difficult, it does provide avenues for providing methods to women who are the victims of domestic violence, before suicide becomes their final option. Provision of prompt and easily available mental health services to these women may be an important factor in reducing the suicide rate in this population.
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