2013. Vol.3, No.2, 137-148
Published Online April 2013 in SciRes (http://www.scirp.org/journal/sm) http://dx.doi.org/10.4236/sm.2013.32021
Copyright © 2013 SciRes. 137
Social-Environmental Factors and Suicide Mortality:
A Narrative Review of over 200 Articles
Allison Milner1, Heidi Hjelmeland2,3, Ella Arensman4, Diego De Leo1
1Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia
2Department of Social Work and H ealth Science, Norwegian U niv ersity of Science and Technology,
3Department of Health Surveillance and Suicide Prevention, Norwegian Institute of Public Health, Oslo, Norway
4National Suicide Research Foundation and Department of Epidemiology and Public Health,
University College Cork, Cork, Ireland
Received December 12th, 2012; revised January 26th, 201 3; accepted February 9th, 2013
Copyright © 2013 Allison Milner et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Suicide mortality in a population has long been thought to be sensitive to social, economic and cultural
contexts. This review examined research on the relationship between social-environmental variables and
suicide mortality published over a ten-year period. The main areas covered in the review included: the
economy and income, unemployment, relationship status, fertility and birth rates, female participation in
the workforce, religion, migration, location of residence, modernisation, media reporting, alcohol, and
access to suicide methods. Results of the review indicated that rates of suicide mortality (deaths per
100,000 in a population) were sensitive to a wide range of social factors. There were relatively stable as-
sociations noted between divorce and unemployment with suicide mortality, while many of the reported
associations between suicide mortality and other social variables (such as religion, fertility and female
participation in the workforce) were influenced by contextual factors and time. These findings indicate the
importance of considering the relationship between social factors and suicide as dynamic phenomena.
Keywords: Suicide; Social Factors; Economic Factors; Review; Durkheim; Suicide Prevention
The relationship between suicide mortality within social,
economic and cultural contexts has been a long-standing area of
interest to suicide researchers. As far back as the late 1800s, it
was argued that the burden of suicide in a society reflected the
political, religious, economic and social environment in which
the behaviour was embedded (Durkheim, 1897). According to
Durkheim’s (1897) social-environmental approach, a marked
change to any of these environmental factors may disrupt pro-
tective and normative social roles, values and relationships, and
is associated with greater risk of suicide. This seminal work has
influenced hundreds of other studies, as summarised in past
review papers (Moksony, 1990; Stack, 1982; Stack, 2000a,
With the last review paper on the topic published over ten
years ago, the present article aimed to provide updated evidence
about the relationship between social-environmental variables
and suicide in a narrative way. The central focus of the review
was on those factors responsive to changes in social environ-
ments, rather than those related to climatic elements, internal
psychological states or biology (e.g., mental illness and genetic
differences between populations). The article particularly fo-
cused on studies assessing economic strain (changes in national
income, income inequality, unemployment and modernisation)
and social bonds in society (such as relationship status, fertil-
ity/birth rates, gender role shifts, religion and migration). This
narrative review also covered research into several other so-
cial-environmental factors shown to have an influence on sui-
cide, including alcohol use in society (Ramstedt, 2001) and
media reports of suicide (Pirkis & Blood, 2001a, 2001b). Dif-
ferences in access to lethal means used in suicide were also
considered, as these have been shown to vary across social
contexts (Ajdacic-Gross et al., 2008).
The search strategy was conducted through five main data-
bases: Scopus, PubMed, Proquest, Sociological Abstracts and
Web of Knowledge. These databases were chosen based on the
content of research covered and the scope and number of jour-
nals indexed. The search terms used in the review targeted
studies focusing on the relationship between suicide and indi-
cators of economic strain (changes in national income, unem-
ployment etc.) and social bonds (relationship and family status
etc.,). Decisions about the indicators to include in the review
were based on discussion with several expert suicide research-
ers and the study authors. The selection of search terms and was
guided by past reviews and research (Stack, 2000a, 2000b) and
included “suicide mortality” and “suicide rates” in relation to
the following: “economy”, “income”, “unemployment”, “rela-
tionship status”, “fertility rate”, “birth rate”, “female labour
A. MILNER ET AL.
force participation”, “gender role”, “religion”, “migration”,
“rural”, and “modernisation”. The review also considered evi-
dence about the prevalence of alcohol, access to common sui-
cide methods, and the influence of media reporting on suicide
(terms included: “alcohol”, “access to means” and “media”) as
all of these areas were deemed to be sensitive to social and
The search parameters of this review were set for research
published from the year 2000 onwards; however, we considered
older literature if no recent research was available or if an older
article made an important empirical or theoretical contribution
The initial search results presented more than 4000 articles.
Out of these, articles published in English peer-reviewed jour-
nals were considered as eligible. As empirically-based studies
were the focus of the review, papers making purely conceptual
or theoretical contributions were excluded. We only examined
studies explicitly considering social and environmental influ-
ences on suicide mortality (usually in the form of suicide
“rates” or deaths in a population).
Articles were then grouped according to subject area. Visual
inspection of all abstracts was conducted in order to determine
relevance to the review. At the end, there were 222 articles that
were read in full for this narrative review.
The Ecological Correlates of Suicide: Empirical
The Economy and Income (n = 39)
Findings from both cross-sectional and longitudinal ecologi-
cal studies indicate that suicide rates are associated with im-
provements and downturns in economic functioning (Baller,
Levchak, & Schultz, 2010; Berk, Dodd, & Henry, 2006;
Chuang & Huang, 2007; Hintikka, Saarinen, & Viinamaki,
1999; Lester & Yang, 1997; Mo niruzzaman & Andersson, 2008;
Tapia Granados & Diez Roux, 2009; Yang & Lester, 2001;
Zhang et al., 2010). An increase in suicide rates appears to be
particularly observable in locations that have experienced rapid
social, political and cultural change (Maag, 2008; Milner,
McClure, & De Leo, 2012; Milner, McClure, Sun, & De Leo,
2011), such as countries of the former USSR (Babones, 2008;
Brainerd, 2001; King, Hamm, & Stuckler, 2009) and in Asia
(Chang, Gunnell, Sterne, Lu, & Cheng, 2009; Khang, Lynch, &
Kaplan, 2005). Research also suggests the association between
the economy and suicide may change over time. For example,
suicide rates may initially decrease during times of economic
improvement but stabilise or increase after a specific level of
economic development has been reached (Yang & Lester, 2001).
Aside from fluctuations in the economy, suicide may also be
influenced by the level of income obtained in a population
(Chang et al., 2011; Sareen, Afifi, McMillan, & Asmundson,
2011; Sher, 2006). A longitudinal (1980-1998) investigation in
over 60 countries found that suicide initially decreased as in-
come per capita rose, but increased after a certain level of in-
come was obtained (Neumayer, 2003). These results support
the ‘Easterlin hypothesis’, which argues that human wellbeing
is contingent on material conditions only until a specific level
of wealth has been achieved, after which wellbeing may depend
on psychological or lifestyle factors (Easterlin, 1974; Graham
& Pettinato, 2002; Pugno, 2009).
Another area of research concerns the relationship between
income inequality and suicide. Researchers have argued that
income inequality creates greater risk for adverse health out-
comes by generating class and social differences in access to
income, education, and health services (Pompili et al., 2011).
The detrimental effect of income inequality may also be con-
nected to a loss of social capital, as well as deprivation and
stress (Kawachi, Kennedy, Lochner, & Prothrow-Smith, 1997;
Wilkinson, 1997). Certainly, research evidence seems to indi-
cate that suicide is highest in those groups most disadvantaged
in society (e.g. lower educational and socio-economic groups)
(Daly & Wilson, 2009; Lorant et al., 2005; Mäki & Martikainen,
2009; Miller et al., 2005; Page, Morrell, Taylor, Carter, &
Dudley, 2006). However, there is mixed evidence about effect
of income inequality at country-level, with a number of studies
reporting no significant relationship with suicide mortality
(Leigh & Jencks, 2007; Lynch et al., 2001; Rodríguez Andrés,
2005), while others indicated an increase in suicide mortality
(De Vogli & Gimeno, 2009; Fernquist, 2003; Gunnell, Middle-
ton, Whitley, Dorling, & Frankel, 2003; Inagaki, 2010). These
conflicting results may be related to methodological factors,
such as problems in the use of proxy variables used to measure
inequality (Babones, 2008). Varia tion in the relationshi p between
inequality and suicide is also likely to reflect country-level
factors, such as exi sting economic and political backgrounds.
Unemployment (n = 30)
While most studies have reported that higher unemployment
is accompanied by an increase in suicide rates (Abe, 2004;
Andres & Halicioglu, 2010; Berk et al., 2006; Blakely, Collings,
& Atkinson, 2003; Chang, Sterne, Huang, Chuang, & Gunnell,
2010; Chen, Yip, Lee, Fan, & Fu, 2010; Chuang & Huang,
2007; Corcoran & Arensman, 2011; Fernquist, 2007; Kuroki,
2010; Lewis & Sloggett, 1998; Lin, 2006; Milner, McClure, et
al., 2012; Preti & Miotto, 1999; Tsai & Cho, 2011; Yamasaki,
Sakai, & Shirakawa, 2005; Ying & Chang, 2009), a smaller
number of studies have found no or mixed evidence of this
association (Chang, Sterne et al., 2010; Crawford & Prince,
1999; Lucey et al., 2005; Platt, Micciolo, & Tansella, 1992).
These differences may be due to the fact that unemployment
is influenced by individual factors associated with both the loss
of a job and suicide, such as mental illness (Agerbo, 2003;
Blakely et al., 2003; Jin, 1995; Noh, 2009). It is also possible
that there are differences based on the length of unemployment,
with several past studies finding the highest risk of suicide oc-
curs within the first few years of unemployment and then de-
creases up to 16 years after the loss of a job (Lundin, Lundberg,
Hallsten, Ottosson, & Hemmingsson, 2010; Milner, Page, &
Lamontagne, 2012). The adverse effect of job-loss may be par-
ticularly accentuated during times of low unemployment in a
population, as this represents a deviation from social norms
(more than in times of high unemployment, when unemploy-
ment may be normative) (Lundin et al., 2010; Martikainen &
Valkonen, 1996; Milner, Page, et al., 2012). The relationship
between unemployment and suicide may also be affected by
other factors such as income per capita. For example, Noh
(2009) found that unemployment was related to an increase in
suicide rates when examined in relation to a higher income, but
not when examined in relation to lower income. Political con-
text, employment conditions and media reporting of suicide in
the country have also been found to be relevant factors (Chen et
Past research indicates that unemployment has a stronger in-
Copyright © 2013 SciRes.
A. MILNER ET AL.
fluence on male suicide than female suicide (Berk et al., 2006;
Blakely et al., 2003; Chan, Yip, Wong, & Chen, 2007; Kuroki,
2010; Preti & Miotto, 1999; Pritchard, 1992; Qin, Mortensen,
Agerbo, Westergard-Nielsen, & Eriksson, 2000). However,
other research casts some doubt on these gender-specific find-
ings (Chen et al., 2010; Kposowa, 2001). Therefore, despite
some differences in results, most research suggests that unem-
ployment increases suicide risk, but this relationship likely to
be influenced by various individua l a n d co n t e xtual factors.
Relationship Status (n = 27)
Findings from studies at both the aggregate and individual
level show that divorce (Andres & Halicioglu, 2010; Chang et
al., 2011; Corcoran & Nagar, 2010; Denney, Rogers, Krueger,
& Wadsworth, 2009; Gunnell et al., 2003; Kposowa, 2000;
Leenaars & Lester, 1999; Masocco et al., 2010; Masocco et al.,
2008; Wu & Bond, 2006), separation (Barstad, 2008; Ide,
Wyder, Kolves, & De Leo, 2011; Wyder, Ward, & De Leo,
2009) and widowhood (Ajdacic-Gross et al., 2007; Corcoran,
2009; Denney et al., 2009; Luoma & Pearson, 2002; Masocco
et al., 2010; Masocco et al., 2008) result in a higher likelihood
of suicide. In comparison, marriage is commonly found to be
negatively related to suicide (Cutright & Fernquist, 2007;
Cutright, Stack, & Ferquist, 2007; Griffiths, Ladva, Brock, &
Baker, 2008; Masocco et al., 2008; O’Reilly, Rosato, Connolly,
& Cardwell, 2008; Qin, Agerbo, & Mortensen, 2003). Some
research has suggested that male suicide is more sensitive to
macro-level indicators of relationship breakdown than female
suicide (Andres & Halicioglu, 2010; Corcoran & Nagar, 2010;
Cutright & Fernquist, 2004; Gunnell et al., 2003; Rodríguez
However, it is likely that the protective effect of marriage is
culturally specific, as research from China shows that family
and relationship stress can increase the risk of suicide in mar-
ried women (Zhang, 2010). Research also suggests that the
association between relationship status and suicide is sensitive
to social change, as well as age, gender and the time period
under analysis (Messner, Bjarnason, Raffalovich, & Robinson,
2006; Pampel, 1998; Trovato, 1987). Other individual and con-
textual factors also considered to be important to the associa-
tion between relationship status and suicide include stigma
towards help-seeking, social isolation, unemployment, and
alcohol and drug use (Masocco et al., 2010). Therefore, it ap-
pears that the protective effects of relationships on suicide are
related to social and cultural norms and individual factors.
Birth Rates (n = 11)
Proxy variables such as fertility and birth rates at the country
level are usually found to be negatively related to suicide
(Andres & Halicioglu, 2010; Bhandarkar & Shah, 2008; Fern-
quist & Cutright, 1998; Leenaars & Lester, 1999; Shah, 2008).
These findings follow Durkheim’s (1897) suggestion that par-
ent-child relationships provide an important source of protec-
tion against suicide (Stack, 1996-1997; Umberson, 1987).
However, the relationship between higher fertility/birth rates
and lower suicide rates may be contingent on normative family
structures in society. For example, research using the indicator
of non-marital births (a proxy used to represent the weakening
of the family institution) has been associated with higher sui-
cide rates in wealthy areas of the world (Messner et al., 2006;
Stockard & O'Brien, 2002). However, research conducted in
Ireland suggests that this association was also sensitive to
changes in social norms over time (Lucey et al., 2005).
Female Participation in the Workforce (n = 18)
Studies conducted in the 1970s and 1980s found that gender
role shifts, measured through indicators such as female labour
force participation (FLFP), were related to higher suicide rates
in wealthy areas of the world (Davis, 1981; Krupinski, 1980;
Lester & Yang, 1991; Newman, Whittemore, & Newman,
1973). Some other studies report a mixed or changing relation-
ship between FLFP and suicide (Burr, McCall, & Powell-
Griner, 1997; Lucey et al., 2005; Stack, 1987; Trovato & Vos,
1992), which may be because social norms and values have
adjusted to female employment in high-income countries over
time (i.e., as female employment does not pose a threat to nor-
mative values or roles in society) (Austin, Bologna, & Hayama
Dodge, 1992; Stack, 2000b). However, other research supports
the idea that female participation in the workforce has an ad-
verse influence on male and female suicide rates (Aliverdinia &
Pridemore, 2009; Cutright & Fernquist, 2001a; Fernquist, 1999;
Fernquist & Cutright, 1998; Milner, McClure, et al., 2012;
Neumayer, 2003; Yamasaki, Araki, Sakai, & Voorhees, 2008).
Some of the reasons for these differences may be connected to
social, economic or cultural differences in the settings under
study. For example, the context of female employment and
suicide in Iran (Aliverdinia & Pridemore, 2009) would be
markedly different from that in high-income western countries
(Cutright & Fernquist, 2001b). These mixed findings suggest
the need for more in-depth research into the relationship be-
tween suicide and gender role changes in the workforce across
cultural and income groups.
Religion (n = 17)
Studies on the relationship between suicide and religion gen-
erally report a negative association, both when measured indi-
rectly (e.g. religious book production, proportion of a specific
religion in the population, ordained clergy rate) (Baller &
Richardson, 2002; Ellison, Burr, & McCall, 1997; Fernquist,
2007; Fernquist & Cutright, 1998) and more directly (e.g.
church adherence, active membership in a religious group,
strength of religious beliefs in society) (Baller & Richardson,
2002; Cutright & Fernquist, 2004; Ellison et al., 1997; Helli-
well, 2007; Neeleman, 1997; Van Tubergen, Te Grotenhuis, &
Ultee, 2005). As with other ecological factors relevant to sui-
cide, the relationship between religion and suicide also appears
to be influenced by cultural contexts (e.g., European versus
Asian areas of the world), gender and age (Clarke, Bannon, &
Denihan, 2003; Colucci & Martin, 2008; Gearing & Lizardi,
2009), as well as changing societal contexts and norms (Cleary
& Brannick, 2007). For example, it has been noted that relig-
ions with stronger affiliations, values and family traditions may
offer greater protection against suicide (Neeleman, 1998;
Neeleman & Lewis, 1999). In agreement with Durkheim (1897),
Faria and colleagues (Faria, Victora, Meneghel, De Carvalho,
& Falk, 2006) identified higher male suicide rates in predomi-
nantly Protestant regions in Rio Grande do Sul. A possible
explanation is that integration and social cohesion is not as
strong in Protestant societies as in Catholic societies. A study
by Pritchard and Baldwin (Pritchard & Baldwin, 2000) also
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A. MILNER ET AL.
reported important differences in respect to age, as elderly peo-
ple in traditional Catholic or Orthodox locations were found to
have higher suicide rates than those in less traditional states. It
is also necessary to consider that religions with a strongly pro-
hibitive attitude toward suicide may reinforce stigma, leading to
greater concealment and inaccurate reporting (van Poppel &
Migrants (n = 20)
There is mixed evidence about the influence of migration on
suicide. While some research supports the premise that migra-
tion is associated with higher suicide rates (Burvill, 1998; Jo-
hansson, Sundquist, Johansson, Qvist, & Bergman, 1997; Stack,
1981; Stack, 2000b; Whitley, Gunnell, Dorling, & Smith, 1999),
this relationship appears to be contingent on individual factors
related to the migrant and their country of origin (Ferrada-Noli,
2007; Hjern, Lindblad, & Vinnerljung, 2002; Johansson, Sund-
quist, Johansson, Bergman, et al., 1997; Kliewer, 1991; Voracek
& Loibl, 2008; Westman, Sundquist, Johansson, Johansson, &
Sundquist, 2006). Migrant suicide is also likely to be influenced
by ethnicity, gender, age, socioeconomic status and residence in
urban or rural area of residence of the host country (Kliewer &
Ward, 1988; Morrell, Taylor, Slaytor, & Ford, 1999; Shah,
Lindesay, & Dennis, 2009; Singh & Siahpush, 2006; Taylor,
Morrell, Slaytor, & Ford, 1998; Trovato & Jarvis, 1986). Fac-
tors such as shorter duration of residence (Hjern & Allebeck,
2002) and relationship status (i.e., single immigrants may have
higher risk) (Kposowa, McElvain, & Breault, 2008) could also
have an influence on migrant suicide rates. A study by Ott and
colleagues (Ott, Winkler, Kyobutungi, Laki, & Becher, 2008)
also suggests that second generation immigrants are at greater
risk of suicide than their parental generation.
Rural Lo cations (n = 26)
Studies from a number of different cultural contexts report
that those living in rural areas are more at risk of suicide than
those living in urban areas (Dudley, Kelk, Florio, Howard, &
Waters, 1998; Gartner, Farewell, Roach, & Dunstan, 2011;
Hempstead, 2006; Kapusta et al., 2008; Kim, Jung-Choi, Jun, &
Kawachi, 2010; Phillips, 2009; Singh & Siahpush, 2002; Yip,
Callanan, & Yuen, 2000). For example, research in Australia
and New Zealand suggests that younger and older males in
rural areas have higher suicide rates than their metropolitan
counterparts (Caldwell, Jorm, & Dear, 2004; Dudley et al.,
1998; Morrell et al., 1999; Yip et al., 2000), while older adults
and females are reported as being more “at risk” in rural areas
of Asia (Liu, Tein, Zhao, & Sandler, 2005; Phillips, Li, &
Zhang, 2002; Pritchard, 1996; Yip et al., 2000). There are a
number of explanations for these geographical differences,
some of which focus on exposure to risk factors (e.g. drugs and
alcohol abuse), prevalence of treatment and support services
(e.g. availability of mental health services), and access to lethal
suicide methods (Caldwell et al., 2004; Hempstead, 2006;
Hirsch, 2006; Judd, Cooper, Fraser, & Davis, 2006; Klieve,
Barnes, & De Leo, 2009; Klieve, Sveticic, & De Leo, 2009;
Konradsen, Hoek, & Peiris, 2006; Konradsen et al., 2003; Rob-
erts et al., 2003; Saunderson, Haynes, & Langford, 1998).
Other researchers focus on the role of cultural norms in rural
and urban areas, and the importance of values and relationships
in the surrounding psycho-social environment (Alston, 2010;
Baller & Richardson, 2002; Dudley et al., 1998; Hirsch, 2006;
Pritchard, 1996). The relationship between rural residence and
suicide has also been found to be sensitive to societal change,
as studies have reported changes in the rural-urban suicide ratio
over time (Chang, Gunnell, Wheeler, Yip, & Sterne, 2010;
Kapusta et al., 2008; Page, Morrell, Taylor, Dudley, & Carter,
2007; Pearce, Barnett, & Jones, 2007).
Modernisation (n = 8)
Durkheim’s (1897) research investigated the influence of
modernisation (conceptualised as the process of industrialisa-
tion, urbanisation and secularisation) on suicide rates in Euro-
pean nations in the late 1800s. According to Durkheim, the
changes modernisation brought to society disrupted regulatory
mechanisms and the social and community bonds that protected
against suicide: “every disturbance of equilibrium, even though
it may involve greater comfort and a raising of the general pace
of life, provides an impulse to voluntary death” (Durkheim,
1897: pp. 206-207). More recent studies on the relationship
between modernisation and suicide rates have produced differ-
ent results (Stack, 2000b). Stack (2000b) presents two possible
reasons for this. Firstly, he argues that after the “initial shocks”
of modernisation have passed, suicide rates in society will cease
to be sensitive to this process. Secondly, the high degree of
correlation between indicators traditionally used as proxies for
modernisation creates methodological complications.
Several recent approaches have attempted to address these
limitations by modifying the concept to include variables that
may better reflect contemporary societies. For example, Fern-
quist and Cutright (1998) used indicators such as telephone
lines per 100 persons and tertiary education enrolments to pro-
vide an updated understanding of modernisation in developed
nations. A study by Vijayakumar and colleagues (2005) pro-
vides another perspective on this topic. These researchers found
that countries with a medium “human development index” (an
aggregate measure of human development in terms of life ex-
pectancy, literacy, and income) had lower suicide rates. Zhang
(1998) measures modernisation through variables such as birth
rate and age distribution of the population, life-expectancy,
urbanisation, percentage of married women using contraception,
and per capita GNP. An alternative approach is presented by
Mäkinen (1997), who measures modernisation through vari-
ables such as marriage and divorce, the percentage of births
occurring outside marriage, female employment, unemploy-
ment, and the ownership of television sets. In 2007, Graeff and
Mehlkopf defined modernisation as a “technical form of social
change” and measured this through indicators such as intensifi-
cation of communication processes and size of the government
(implying the effect of the government on social welfare). Most
recently, a study using an aggregate measure of globalisation
found that this was associated with higher suicide rates in 35
areas of the world (Milner et al., 2011). However, it is worth
noting that the studies presented above deviate from the origi-
nal concept of modernisation described by Durkheim (1897).
Media Reporting of Suicide (n = 19)
Media guidelines for the reporting of suicide are commonly
included in national intervention efforts because of the concern
that insensitive descriptions may result in an increase in suicide
deaths (Cheng, Hawton, Lee, & Chen, 2007; Fu & Yip, 2007;
Pirkis, Blood, Beautrais, Burgess, & Skehans, 2006; Stack,
Copyright © 2013 SciRes.
A. MILNER ET AL.
2009). There is some evidence to support this perspective, as
recent research papers identify an increase in suicide rates after
damaging media reports (Chen et al., 2010; Chen, Chen, & Yip,
2011; Fu, Chan, & Yip, 2011; Gould, 2001; Hagihara, Tarumi,
& Abe, 2007; Niederkrotenthaler & Sonneck, 2007; Pirkis &
Blood, 2001a, 2001b; Stack, 2005; Sudak & Sudak, 2005; Tsai
& Cho, 2011). This relationship appears to be stronger for fac-
tual media reports (Cheng, Hawton, Chen et al., 2007; Cheng,
Hawton, Lee et al., 2007; Niederkrotenthaler et al., 2009; Pirkis
& Blood, 2001a; Yip et al., 2006) than for fictional reports of
suicide (e.g. films, television, music etc.) (Pirkis & Blood,
2001b). Further, a meta-analysis of 55 studies on non-fictional
accounts found that stories related to entertainment or political
suicides were more often associated with a rise in suicide
(Stack, 2005). This review also found substantially more imita-
tive effects for female suicide rates than male rates, and less
likelihood of imitative effects in younger or middle aged groups.
The association between media reporting and suicide is also
dependent on the length of time between the occurrence of the
suicide and publishing of the story, the number of media
sources covering the event, and the specific characteristics of
case (Pirkis et al., 2006). Recent research by Niederkroten-
thaler and colleagues (2010) reports that printed media articles
that focused on specific suicide deaths and “myths” of suicide
had a detrimental effect, while those articles on coping behav-
iours and suicide ideation (not accompanied by suicidal behav-
iours) were not associated with an increase in suicide. Nied-
erkrotenthaler and Sonneck (2007) also reported that imple-
menting media guidelines was related to more appropriate me-
dia reporting of suicide and reduced suicide rates. The mode of
coverage is also likely to be important, with television stories
being less conducive to imitative effects than newspaper stories
Alcohol (n = 17)
Alcohol has been linked to increased country-level suicide
rates in Europe, Canada (Hintikka et al., 1999; Inelmen, Gaz-
erro, Inelmen, Sergi, & Manzato, 2010; Landberg, 2008; Mann,
Zalcman, Smart, Rush, & Suurvali, 2006; Ramstedt, 2001) and
in Japan (Nakaya et al., 2007). Alcohol is also thought to be
associated with higher rates of suicide in some Indigenous
groups and in the Pacific, although empirical data on this rela-
tionship is scarce (De Leo, Milner, & Sveticic, 2012; Laliberté
& Tousignant, 2009; Rubinstein, 1992). At a social level, these
associations may vary depending on gender, the prevalence and
type of alcohol available, and the attitude toward alcohol con-
sumption in society (Bloomfield, Stockwell, Gmel, & Rehn,
2003; Kuendig et al., 2008; Landberg, 2008, 2009; Norström &
Skog, 2001; Peele, 1997; Rossow, 1996). For example, the
relationship between suicide and alcohol consumption per cap-
ita appears to be more noticeable in countries where spirit con-
sumption is high (such as those in Eastern Europe), compared
to countries with moderate drinking practices (Inelmen et al.,
2010; Landberg, 2008; Pridemore, 2006; Stickley, Jukkala, &
Norstrom, 2011). These findings indicate the importance of
considering the national cultural attitude toward alcohol, as
well as the actual prevalence of alco h ol in a country.
Access to Suicide Methods (n = 21)
In western countries, a large number of suicide deaths occur
by hanging, while pesticide poisoning is a major cause of death
in Asia and Latin America (Ajdacic-Gross et al., 2008; Kon-
radsen et al., 2006; Konradsen et al., 2003; Mohamed et al.,
2009; Roberts et al., 2003). There are also noticeable gender
differences in the use of suicide methods in many countries,
with females more likely to overdose on drugs or poisons,
while men tend to use methods such as hanging and firearms
(Hawton, Fagg, Simkin, Harriss, & Malmberg, 1998; Payne,
Swami, & Stanistreet, 2008). It is likely that these differences
reflect both cultural and social attitudes towards specific
method choice, as well as more pragmatic considerations about
the availability of methods (Kanchan, Menon, & Menezes,
2009; Lin, Chang, & Lu, 2010).
Reducing access to commonly used methods (e.g. tighter
regulation and access to firearms, illegal and legal drugs, agri-
cultural pesticides and domestic gas) has been associated with
lower suicide within some populations (Beautrais, Fergusson,
& Horwood, 2005; Daigle, 2005; Hawton, 2007; Nordentoft,
Qin, Helweg-Larsen, & Juel, 2006, 2007; Rodríguez Andrés &
Hempstead, 2011; Skegg & Herbison, 2009; Wong, Chan, Lau,
Morgan, & Yip, 2009). However, research also suggests the
importance of considering the risk of method substitution
(whereby suicidal persons prevented from using one method
will shift consideration to an alternate method) and the other
possible influences such as the degree of familiarity with the
method, gender, age and geographical location (De Leo, Dwyer,
Firman, & Neulinger, 2003; De Leo, Evans, & Neulinger, 2002;
Klieve, Barnes et al., 2009; Klieve, Sveticic et al., 2009; Rob-
erts et al., 2003).
This review covered an extensive number of studies, all of
which used different approaches and methodologies to examine
the relationship between social-environmental factors and sui-
cide mortality. The outcomes of the review indicate that suicide
is influenced by a wide range of factors such as income (na-
tional income, income per capita), employment trends (unem-
ployment and female labour force participation), family bonds
and relationships (fertility, relationship status), religion, loca-
tion of residence, media reporting of suicide, access to alcohol
in society, and lethal means used to suicide. The loss of a
spouse (either through divorce or widowhood) appears to be
associated with an increase in suicide rates, while female
workforce participation, fertility/birth rates, and religion appear
to vary over time and between contexts.
As a methodological comment, the research discussed in this
paper was conducted using different designs at both the aggre-
gate and individual level. Numerous studies used ecological
designs (e.g., Babones, 2008; Berk et al., 2006; Brainerd, 2001;
Chang et al., 2009; Chuang & Huang, 2007; Durkheim, 1897;
Hintikka et al., 1999; Milner, McClure et al., 2012; Milner et al.,
2011; Milner, Page et al., 2012) either measured over time
while fewer used cohort designs (Lundin et al., 2010; Mäki &
Martikainen, 2009; Pritchard, 1992; Qin et al., 2003; Qin et al.,
2000). The rationale for using ecological designs as they are
able to measure social phenomena or states in relation to death
in a population, while cohort studies can control for possible
individual confounding factors, such as education or occupa-
Various limitations may have influenced the findings of this
review. First, the holistic nature of it means that our review did
not discuss methodological or analytic aspects of research arti-
Copyright © 2013 SciRes. 141
A. MILNER ET AL.
cles. However, the aim of this paper was to provide an over-
view of the general findings on these topics rather than provid-
ing specific detailed information on a topic. Indeed, each on the
topics discussed in this paper could be (and potentially should
be) the topic of a whole other paper. Another limitation is that
the review did not distinguish between compositional (e.g. the
characteristics of individuals concentrated within particular
places) or contextual effects (e.g. factors in the local physical or
social environment) (Macintyre, Ellaway, & Cummins, 2002).
As we focused only on suicide mortality, it is not possible to
generalise the outcomes of this review to non-fatal suicidal
behaviours. There are also limitations concerning the design of
the study and a number of relevant research papers may have
been missed due to the selection of search terms or databases
used. Further, the search strategy was skewed towards research
from high-income areas due to lack of published data from
low-income areas of the world (Bertolote, Fleischmann, De Leo,
& Wasserman, 2004).
Another issue was the continued reliance on material pub-
lished from before the year 2000. This may have reflected dif-
ferences in research interest over time. For example, there has
been relatively little attention to the topic of gender role change
in recent years, while topics like media reporting or unem-
ployment have been the focus of a number of recent research
articles. It is also necessary to note that investigation into some
social factors, such as economic change, have a longer history
of research than o t h e r s .
The dynamic relationship between social-environmental fac-
tors and suicide indicates the importance of longitudinal and
contextually specific studies able to identify time intervals at
which the relationship between social variables and suicide is
most salient. These findings can also be important for suicide
prevention. For example, research on “acute” points during
which unemployment, migration or divorce are associated with
the greatest likelihood of suicide may be able to inform risk
assessment and the development of targeted population-level
interventions. Research by Stuckler, Basu, Suhrcke, Coutts and
McKee (2009) provide evidence of the public health effects of
economic crises, in particular in terms of increasing suicide
rates. The authors underline the importance of active labour
market programs (e.g., those that keep and reintegrate workers
in jobs) in mitigating some adverse health effects of economic
The high suicide risk among people living in rural areas un-
derlines the need to invest in prevention programs specifically
targeting rural areas, such as those aimed at improving the
skills of the general population in order to manage mental
health emergencies including suicidal behaviour (Ellis & Philip,
2010). However, in general, evidence suggests that reductions
in suicide of a population can be achieved through programs
containing multiple levels of intervention and which target
several at-risk groups (Hegerl, Althaus, Schmidtke, & Nik-
Social and environmental contexts present a range of possi-
ble and heterogeneous influences on suicide mortality. This
review covered recent research about a wide range of factors
including income (national income, income per capita), em-
ployment trends (unemployment and female labour force par-
ticipation), family bonds and relationships (fertility and rela-
tionship status), religion, location of residence, media reporting
of suicide, access to alcohol in society, and lethal means used to
suicide. The strength and direction of some of these associa-
tions (e.g., female labour force participation, fertility and relig-
ion) appear to vary over time and between contexts. The influ-
ence of other factors such as relationship status and unemploy-
ment appear to be comparatively more stable. Aside from being
of interest to social researchers, the findings of this review
could be of relevance to policy develop as they highlight the
importance of social-environmental factors as protective and
risk factor for suicide mortality across population.
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