Suicide research in Sweden from the early 1990’s until 2014
This review of suicide research in Sweden from the early 1990’s until 2014 was written by NASP, June 2014.
Description of the research
Suicide is a major public health problem worldwide and suicide research activities are therefore imperative. In Sweden, suicide research can be categorized into eight somewhat overlapping research areas: 1, epidemiology and register studies; 2, neurobiology and genetics; 3, suicide risk assessment, 4, treatment and care; 5, public health interventions; 6, suicide bereavement and euthanasia; 7, suicide in low- and middle-income countries (LAMIC); as well as the 8, suicidal experience and process in general. The description below is a short report of the Swedish suicide research produced from the early 1990’s, published in international scientific journals. The scope of this review was limited to studies with an exclusive focus on the topic of suicidality. Papers related to, for instance, the determinants of depression, schizophrenia, or other mental health problems without an explicit intent to investigate suicidality were not included. Over of 540 papers were reviewed (see appendix) of which approximately 130 are cited in this document as examples of Swedish suicide research.
Epidemiology and register studies
A large number of studies from Sweden have focused on identifying factors associated with suicide. The aim of this type of research is to identify factors that can be addressed to reduce suicidality and to improve suicide risk assessment. For example, research targeting different aspects of alcohol consumption such as the early studies by the research group of Wasserman et al. (e.g., Wasserman, Värnik, & Eklund, 1994, 1998; Wasserman & Värnik, 1998) and Berglund et al. (e.g., Berglund & Ojehagen, 1998; Berglund, 1984) have increased the knowledge about the association between harmful use of alcohol and the risk of suicide. These studies have had significant international impact. Similarly, a large number of studies have focused on the association of mental disorders to suicidality. These include research by the groups of Runeson et al. (e.g., Tidemalm, Långström, Lichtenstein, & Runeson, 2008), Wasserman et al. (e.g., Balázs et al., 2013; Bertolote, Fleischmann, De Leo, & Wasserman, 2003; 2004), Nordström et al. (e.g., Carlborg, Jokinen, Nordström, Jönsson, & Nordström, 2010; Carlborg, Winnerbäck, Jönsson, Jokinen, & Nordström, 2010) and Berglund et al (e.g., Brådvik & Berglund, 2010, 2011). In addition, research in Sweden has also been focused on understanding and identifying other individual risk factors that relate to suicidal behaviours. These include exposure to adversity (e.g., Söderberg, Kullgren, & Salander Renberg, 2004), personality traits (e.g., Allebeck, Allgulander, & Fisher, 1988; Hirvikoski & Jokinen, 2012), intelligence (e.g., Gunnell, Magnusson, & Rasmussen, 2005), and physical illness and features (e.g., Allebeck, Bolund, & Ringbäck, 1989; Jiang, Rasmussen, & Wasserman, 1999; Magnusson, Rasmussen, Lawlor, Tynelius, & Gunnell, 2006; Sundström et al., 2010), as well as research family, relationship, life-styles and other societal factors (e.g., Carli, Mandelli et al., 2014; Ferrada-Noli & Asberg, 1997; Durkee et al., 2012; Johansson, Sundquist, Johansson, Qvist, & Bergman, 1997; Kuramoto & Runeson, 2013; Magne-Ingvar, Ojehagen, & Träskman-Bendz, 1992; Mittendorfer-Rutz, Rasmussen, & Wasserman, 2004; Moniruzzaman & Andersson, 2004; Sarchiapone et al., 2014; Schmidtke et al., 1996). A number of studies in Sweden have also focused on understanding the prevalence, trends and patterns of suicide in Sweden, Europe and the world through epidemiological studies (e.g., Chotai & Salander Renberg, 2002; Cullberg, Wasserman, & Stefansson, 1988; Runeson, Tidemalm, Dahlin, Lichtenstein, & Långström, 2010; Schmidtke et al., 1996; Schmidtke et al., 1999; Värnik & Wasserman, 1992; Värnik, Kõlves, & Wasserman, 2005; Wasserman & Värnik, 1998a).
Although some risk factors for suicide are non-modifiable, such as gender, these can be useful in identifying risk groups. Selective suicide-prevention interventions can then target other modifiable risk factors, such as mental disorders, that may be present among a risk group. Research in Sweden concerning high risk groups has mainly focused on understanding suicidal behaviours among young people (e.g., Brunner et al., 2014; Carli, Hoven et al., 2014; Hawton et al., 1998; Hultén et al., 2001; Kosidou et al., 2013; Runeson & Beskow, 1991; Runeson, 1990; Mittendorfer-Rutz & Wasserman, 2004; Wasserman, Cheng, & Jiang, 2005) the elderly (e.g., De Leo et al., 2001; Fässberg et al., 2012; Rubenowitz, Waern, Wilhelmson, & Allebeck, 2001; Waern, Rubenowitz, & Wilhelmson, 2003; Waern, Rubenowitz, et al., 2002; Waern, Runeson, et al., 2002) and among immigrants and adoptees (e.g., Bursztein Lipsicas et al., 2012; Ferrada-Noli, Asberg, Ormstad, & Nordström, 1995; Hjern & Allebeck, 2002; Hjern, Lindblad, & Vinnerljung, 2002; Värnik, Kolves, & Wasserman, 2005) as well as the unemployed (Garcy & Vågerö, 2012; 2013; Lundin, Lundberg, Allebeck, & Hemmingsson, 2012).
Neurobiology and genetics
The risk of suicide can also be influenced by individual vulnerability or resiliency related to genetic and biological factors. For example, the role of genetics in suicidal behaviours has been investigated extensively by the research group of Wasserman et al. (e.g., Ben-Efraim, Wasserman, Wasserman, & Sokolowski, 2013; Geijer et al., 2000; Sokolowski, Ben-Efraim, Wasserman, & Wasserman, 2013; Sokolowski, Wasserman, & Wasserman, 2010; Wasserman, Terenius, Wasserman, & Sokolowski, 2010), with particular focus on gene-environment interactions regarding serotonergic as well as HPA-axis related genes. The group of Åsberg and Träskman-Bendz et al. has investigated genetic and also neurobiological markers of suicidal behaviour such as specific serotonergic, dopaminergic and HPA activity (e.g., Engström, Alling, Blennow, Regnéll, & Träskman-Bendz, 1999; Jones et al., 1990; Nässberger & Träskman-Bendz, 1993; Träskman, Asberg, Bertilsson, & Sjöstrand, 1981; Träskman et al., 1980), as has the research group of Nordström (e.g., Jokinen, Nordström, & Nordström, 2009; Jokinen & Nordström, 2009; Nordström & Åsberg, 1992) but also others (e.g., Asberg, 1997; Lidberg, Åsberg, & Sundqvist-Stensman, 1984; Lidberg, Tuck, Åsberg, Scalia-Tomba, & Bertilsson, 1985). Suicidality has also been investigated in relation to the biology of mental disorders (Ekström, Lavebratt, & Schalling, 2012; Johansson et al., 2001) as well as inflammatory factors (Hallberg et al., 2010; Janelidze, Mattei, Westrin, Träskman-Bendz, & Brundin, 2011).
Suicide risk assessment
Suicide assessment for identifying individuals at suicide-risk through screening tools has also been studied extensively in Sweden. Focus has been on the development of new psychometric tools, as well as validating existing ones (Jokinen et al., 2010; Stefansson, Nordström, & Jokinen, 2012; Waern, Sjöström, Marlow, & Hetta, 2010). Psychological tests have also been developed for screening, such as those measuring participants reactions to subliminal exposures of clinically specific stimuli (Titelman, Nilsson, Estari, & Wasserman, 2004; Titelman, Nilsson, Svensson, Karlsson, & Bruchfeld, 2011) as well as biochemical/biological tests looking at dexamethasone suppression or skin conductance (Jokinen et al 2008; Thorell et al 2013).
Treatment and care
The research in Sweden regarding the treatment of suicidality has mainly been focused on psychopharmacological treatment with antidepressants (e.g., Brådvik & Berglund, 2011a; Isacsson, Holmgren, Wasserman, & Bergman, 1994, 1995; Göran Isacsson, Rich, Jureidini, & Raven, 2010). Other studies researched the management, follow-up and care of suicidal people in both Sweden and Europe (e.g., Bursztein Lipsicas et al., 2014; Hultén et al., 2000; Runeson & Wasserman, 1994; Talseth, Lindseth, Jacobsson, & Norberg, 1999).
Public health interventions
A number of large-scale international randomised controlled trials (RCT) of awareness and coping skills increasing programmes among young people have been coordinated by the Swedish research group of Wasserman in collaboration with several EU countries but not in Sweden. These have investigated the effectiveness of suicide prevention programmes aimed at the specific subgroups of the general public, such as adolescents (e.g., Balázs et al., 2013; Brunner et al., 2014; Carli, Hoven et al., 2014; Carli et al., 2013; Hoven, Wasserman, Wasserman, & Mandell, 2009; Kaess et al., 2013; Sarchiapone et al., 2014; C. Wasserman et al., 2012; D. Wasserman et al., 2010). In addition, early work by Rutz has investigated the effectiveness of programmes for training health workers (e.g. GPs) for suicide prevention (e.g., Rutz, von Knorring, & Wålinder, 1989; Rutz, Knorring, Pihlgren, Rihmer, & Wålinder, 1995) with influence to other European countries. Other research in Sweden regarding public health has been focused on understanding attitudes towards suicidal people across different groups (e.g., Renberg & Jacobsson, 2003; Samuelsson, Asberg, & Gustavsson, 1997), investigating the effects of alcohol-related policies for suicide prevention (e.g., Wasserman & Värnik, 1998b; Wasserman, Värnik, Kolves, & Toodling, 2007) and restricting access to common means of suicide (e.g., Beskow, Thorson, & Öström, 1994).
Suicide bereavement and euthanasia
Studies in Sweden have also focused on understanding the impact on friends and family of suicide attempters and completers (e.g., Magne-Ingvar & Öjehagen, 1999; Omerov, Steineck, Nyberg, Runeson, & Nyberg, 2013; Runeson & Beskow, 1991b; C. Wasserman et al., 2012) and euthanasia, (e.g., Wasserman, 1989).
The suicidal experience and process
Studies on the suicidal experience and process are important for increasing the knowledge about suicidality and the improvement of treatment, care and prevention of suicide. Although research focusing on the patients’ experience and the process of suicidality is generally limited, a number of Swedish studies have focused on understanding suicidality and provided insight into these issues (e.g., Hjelmeland et al., 2002; Omma, Sandlund, & Jacobsson, 2013; Runeson, Beskow, & Waern, 1996; Wasserman 1990a; 1990b).
A number of studies in Sweden have carried out research regarding suicide in low-and middle-income countries. These include for example research regarding the prevalence, risk and protective factors, interventions, understanding the suicidal process and expression, and attitudes toward suicide in LAMIC countries (e.g., Ahmadi, 2007; Bertolote et al., 2005, 2010; Burrows & Laflamme, 2008; Fleischmann, 2008; Fleischmann et al., 2005; Mofidi, Ghazinour, Salander-Renberg, & Richter, 2008; Ovuga, Boardman, & Wasserman, 2005; Rodríguez, Caldera, Kullgren, & Renberg, 2006; Sundbom, Jacobsson, Kullgren, & Penayo, 1998; Thanh et al., 2005).
Impact, Strengths and weaknesses
Swedish suicide research using epidemiological, cohort and other designs, aimed at identifying correlates to suicidality has a significant impact on the general understanding of risk and protective factors in suicide. The research carried out using the numerous high quality registries in Sweden and findings have great synergistic potential with other international research. However it’s important to note that risk-and protective factors identified in high income countries might not be applicable or even valid predictors of suicide in LAMIC countries (due to contextual differences). Intercultural and international application of the epidemiologic findings can in this way be challenging.
Most epidemiologic, genetic neurobiological research programmes are aimed at identifying correlates to suicidal behaviour. Although this type of information is useful in screening programs, it is difficult to assess what actual role these correlates play in the causal process that precedes a suicide. Specific studies aimed at disentangling the relationship between correlates, causes and effects make up a small proportion of the research in suicide in Sweden and elsewhere.
Swedish research programmes aimed at the rigorous evaluation of suicide prevention activities on universal, selected or indicated populations appear to be high in quality even compared to other international research, but unfortunately low in quantity (perhaps reflecting a lack of research funding).
In conclusion, suicide research conducted in Sweden is of high quality and has a significant international impact. Research group leaders create a strong next generation of researchers who provide a strong ground for the continuity and sustainability of future suicide research in Sweden.
In order to implement the nine suicide preventive strategies approved by the Swedish parliament and the Swedish government (Regeringsprop 2007/08:110) there is a considerable lack of the following research in order to assure a scientifically grounded implementation. Therefore, I recommend support to studies according to the list below.
Intervention studies of suicide preventive methods in schools, workplaces and at the community level.
Clinical treatment studies of well-defined (phenotype and genotype) psychiatric patient groups.
Qualitative studies on how to improve the adherence, and implementation of policies and guidelines in public health and clinical suicide prevention.
Studies regarding the effects of taboo and stigmatization surrounding suicide, on public health and clinical actions.
Studies focused on anthropological aspects of suicidality and suicide prevention in minorities and in cross-cultural settings.
Studies aimed at the rigorous falsification or validation existing psychological and neurobiological models of suicidality.
In the following strong areas of suicide research in Sweden, continued support of ongoing studies is needed:
Studies designed to utilize the information from available high quality registers in Sweden.
Research on neurobiological and genetic factors.
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