This research upon which this article is based is from a program of work examining the trans-generational impact of the Troubles’ legacy on mental health and suicide in Northern Ireland, funded by the Commission for Victims and Survivors Northern Ireland and the Research and Development Division of the Northern Ireland Public Health Agency.
It is now generally recognized that the events of the Northern Ireland Troubles—a term used to refer to the violent political civil unrest that erupted in the late 1960s and spanned the next 30 years —have had a profound effect on the mental health of the population. The post-conflict period also has seen a rise in the suicide rates and there is speculation regarding the role of the Troubles in explaining this rise (Tomlinson, 2012).
This article considers evidence from the Northern Ireland Study of Health and Stress and the database of deaths by suicide in Northern Ireland on the associations between suicidal behaviour and exposure to the Troubles. It examines the environmental and contextual predictors of population suicide rates, the association between the Troubles, mental disorders and suicide, the association between trauma exposure and suicide and the links with medication and alcohol use.
The database of suicides in Northern Ireland was developed using the coroner’s files on suicides and undetermined deaths. Following ethical approval from Ulster University Research Ethics Committee, the electronic database was compiled by Dr Colette Corry. Each case of undetermined death or ICD ‘suicide’ was given a unique code, information from the files were binary coded and unusual cases were coded ‘other’ to protect anonymity. Information on events prior to death was obtained from police reports; medical details and prescribed medications were provided by General Practitioners (GPs).
Culture and connectedness
A total of 1682 deaths occurring between 2005 and 2011 were included in the database. Of these 284 are recorded as ‘undetermined cause of death’. As reported previously (O’Neill et al., 2014), men were notably overrepresented (78%), with an overall average age of 40.3 years (SD=16.04). Men were, on average, younger than women. The highest incident rate in women occurred among those aged 35-44 years, while for men those aged 16-24 demonstrated higher proportions. The lowest overall rates were seen in those aged 65 years and over. The cohort of people who were most at risk of suicide several decades ago, younger males, continue to remain at risk as they grow older.
In Northern Ireland, this is the population who witnessed the years of the conflict when violence was at its peak. This is in keeping with Tomlinson’s (2012) contention that the increased rates of suicide in Northern Ireland are a consequence of the decline in social cohesion and social connectedness which was a characteristic of the conflict. Many theories of suicide argue that social cohesion and connectedness prevent action to address suicidal ideation; that people who feel suicidal may not act on those feelings because they do not wish to go against the norms and ideals of their social groups (Joiner, 2005). The breakdown in those social structures during the Troubles, along with exposure to violence and high levels of mental disorders, may therefore have contributed to the increase in suicide rates.
Violence, trauma, and completed suicide
There are two main pathways linking an individual’s experience of a traumatic event and death by suicide. The experience of trauma may directly increase the risk of suicide, or the experience of trauma may lead to the development of mental disorders, which are subsequently associated with suicide. In keeping with the theory of a direct link between suicide and trauma, it has been argued that trauma and violence can contribute to an acquired capability for suicide (Klonsky & May, 2014; Joiner 2005; O’Connor, 2011).
This means that witnessing death, violence or pain, increases the person’s risk of transitioning from suicidal thoughts and plans to actions: suicidal gestures and attempts. This acquired capability may be achieved through exposure to pain and violence either directly or indirectly.
Findings from the Northern Ireland Study of Health and Stress were used to elucidate both the direct and indirect links between trauma and suicide. The study revealed that high proportions of the population have witnessed traumatic events; Bunting et al. (2013) estimates that almost 4 in 10 of the Northern Ireland population have been exposed to conflict related traumatic events with one in five people reporting seeing the death or serious injury of another person.
This, along with media coverage of the violence, constitutes exposure to pain and violence which could contribute to acquired capability. The associations between exposure to conflict related trauma and suicide was also evidenced in the findings of the predictors of suicidal ideation, plans and attempts in the Northern Ireland study of health and stress. This study showed that exposure to conflict related trauma further increased the risk of suicide ideation and plans, but not attempts, suggesting an increased likelihood of death at first suicide attempt (O’Neill, 2014a).
Conflict as a predictor of mental disorders and subsequent suicide
Mental disorders were recorded for 58 percent (n=964) of those who died by suicide, however this is likely to be an underestimation because many of the mental health problems in this group are not disclosed. The Northern Ireland Study of Health and Stress (SHS) found that over 39 percent of the population met the criteria for a mental disorder at some point in their lifetime (Bunting et al., 2012a). The rates of mental disorders in Northern Ireland were among the highest of the countries involved in the WMH initiative worldwide; and at 8.8 percent, rates of Posttraumatic Stress Disorder were the highest of all the countries involved in these studies (Ferry et al., 2013).
The conflict may help explain the elevated levels of mental health problems in Northern Ireland. In the Northern Ireland SHS individuals who stated that they had lived “as a civilian in a place where there was ongoing terror of civilians for political, ethnic, religious or other reasons” were almost twice as likely to have mental disorders (Bunting et al., 2012a). There is also evidence that people in Northern Ireland who have experienced conflict related traumatic events are more likely to have suicidal ideation and plans than those with other types of traumas, even when the effects of mental disorders are controlled for (O’Neill et al., 2014a).
Given the evidence that the excess of mental disorders in Northern Ireland may be attributable to exposure to traumatic events related to the conflict, it is reasonable to suggest that many of the suicides associated with those mental disorders are also therefore a consequence of those traumatic events. Furthermore, we might assume that disproportionate numbers of individuals with a mental disorder who died by suicide have experienced conflict-related traumas because these trauma are associated with a higher risk of suicidality.
The conflict was also associated with economic and social disadvantage, childhood adversities generally and maladaptive parenting. These, even in the absence of exposure to conflict related traumatic events, increase the risk of mental disorders, which in turn heighten the risk of suicide (O’Neill et al., 2015).
Use of medication and suicide
There appeared to be high rates of medication use among those who died by suicide and this is likely to be primarily associated with the presence of physical and mental disorders among the deceased. However, there are also links between the use of medication for mental disorders and experiencing traumatic events related to the troubles which merit investigation.
In those who died by suicide, almost two thirds (65.1 percent) of the sample had a recorded use of prescribed medication. In over half of the cases there was prescribed medication for mental health disorder, with one in five taking a psychotropic medication exclusively. The most commonly prescribed medications in this group were antidepressants (37.3 percent) (O’Neill et al., 2015).
The high rates of medication use among those who died by suicide mirror the high rates of medication use in Northern Ireland generally. The Northern Ireland Study of Health and Stress 2005-2008 revealed rates of use of psychotrophic medication of 14.9 percent, and showed that 38.5 percent of people who met the criteria for a 12 month disorder had taken any psychotropic medication.The figures may simply reflect the high rates of mental disorders and a greater cultural acceptability of the use of medications in their treatment.
However there is evidence that people who have experienced a traumatic event associated with the Troubles have an even higher likelihood of using psychotropic medications, particularly hypnotics and antidepressants (Benson et al., 2014). One theory is that exposure to traumatic events is associated with chronic and more serious disorders (Ferry et al., 2014) with specific symptoms which increase the likelihood of medication use rather than alternative treatments.
For example, one feature of exposure to trauma and subsequent PTSD, is nightmares and flashbacks, another is numbing and avoidance. Both of these symptom clusters may be addressed by medication, particularly hypnotics and sedatives, in the absence of alternative treatments, Bunting et al., 2013 reported that under half (40 percent) of people who had a mental disorder in the past 12 months received any treatment.
Alcohol and suicide in Northern Ireland
Alcohol was the most common substance found in those who had died by suicide, it was present in 41 percent of cases and was more common among males and young people, however in some of these cases it was not possible to establish the alcohol levels because it was not possible to assess alcohol levels post-mortem. Males were more likely to have taken alcohol (46 percent) than females (33.9 percent). Those aged between 20 and 29 years were less likely to have a zero blood/urine alcohol reading (36.3 percent) than other age cohorts.
There are various explanations for this pattern, some of the deceased would have had alcohol disorders, some would have used alcohol to deal with emotional problems, and in certain cases the impulsivity associated with the effects of alcohol may have contributed to the suicide. Alternatively, individuals may have taken alcohol to reduce the fear or pain. Alcohol use is common and the abuse of alcohol has widely been regarded as a way that the population has managed the mental health effects of the conflict.
Adverse life events, death by suicide and associations with the conflict
This category included romantic relationships those who were both married or co-habiting, dating relationships as well as peer relationships. The death/illness category (12 percent) included the deaths or illnesses of,among others, spouse,family members and romantic partners. This category also included the deaths of others by suicide. The “Fears for own health” category (7.9 percent) included those with chronic health conditions, accidents, disability or a recent diagnosis. Financial/employment crisis (12.8 percent) included reports of recent job loss or bankruptcy, debt worries and business failure or employment difficulties related to issues such as fear of redundancy and pending disciplinary action.
Stressors and life events are widely agreed to have a role in the development of suicidal behavior (Foster, 2011; O’Connor, 2011). In the Northern Ireland suicide database 61 percent of cases had experienced adverse events prior to death. Relationship difficulties were the most commonly recorded adverse event experienced by the deceased (34.1 percent). This figures rises to over 40 percent when we include difficulties in other types of relationships.
The death and illness category included the loss of, among others, spouse, family members, and a romantic partner (over one in 10). Chronic health conditions or a recent diagnosis was recorded in around 7 percent of cases and financial crisis (recent job loss or bankruptcy, debt worries and business failure), or employment concerns, were also recorded for one in 10. The adverse events were examined for evidence of events relating to the Troubles.
Only a very small number of Troubles related events and circumstances events were reported, these included experiences of threat, exposure to violent events and deaths of people who had participated as members of the police, military or paramilitary groups.
Adverse life events that are associated with suicide are also those which are associated with the conflict’s legacy. Employment status is one such factor since many studies have demonstrated a link between unemployment and suicidality (Eliason & Storrie, 2009; Lundin & Hemmingsson, 2009; Schneider et al., 2011). This is particularly the case for males, and is reflected in the analysis of the data on deaths by suicide in Northern Ireland which shows us that at least half of those who died by suicide were known to be unemployed and financial or employment related problems were recorded prior to the death in one in 10 cases.
Financial concerns may also be related to employment issues, or associated with debts. Again, given that we know that many of the most deprived areas of Northern Ireland have been most affected by the Troubles, it is reasonable to assume that some of these cases are also connected in some way with the troubles.
The largest category of adverse event, experienced by a third of those who died by suicide, was that of relationship breakdown or discord. The association between relationship status and suicide is also demonstrated by the fact that almost half of the deceased were single at time of death (47 percent) and 17.5 percent had experienced a marriage breakdown.
Relationship status and living conditions are also associated with each other, and the high numbers of the deceased who lived alone or who were separated or divorced reinforces the link between relationship difficulties, living conditions and suicide. It is not possible to determine the proportion of these cases attributable to the conflict, however it is likely that events related to the conflict and circumstances caused by the legacy of the conflict are relevant in some cases.
Finally, one in ten (10.7 percent) of those who died by suicide have recorded events relating to experiences of death and grief, a proportion of which will have been directly or indirectly attributable to the Troubles (O’Neill et al., 2015).
The evidence demonstrates that the Troubles are linked to suicides in a variety of ways. Through mapping these connections to theories of suicide we gain an understanding of some of the mechanisms connecting our history of violence with the current elevated rates of suicide.
It is vital that efforts continue to collect data on deaths by suicide in a more systematic way to increase the validity of the data and enhance our understanding of suicide in the Northern Ireland context. They support the need for suicide prevention initiatives to target not only the identification and treatment of those with mental disorders, but also those whose social circumstances and life experiences elevate their risk further.
This invariably includes individuals and communities exposed to the conflict. We need to acknowledge the fact that individuals exposed to the conflict may not come forward for mental disorder treatments because avoidance, denial and emotional numbing are characteristics of how people respond to trauma and are symptoms of PTSD.
It is therefore essential that we explore new ways of targeting and meeting the needs of this vulnerable group of people, who may be described as victims of the conflict.
About the Authors
Siobhan O’Neill is a professor of mental health sciences at Ulster University. She trained as and is a chartered health psychologist. She was a coordinator of the NI Study of Health and Stress and the NI Suicide Study.
Brendan Bunting is a professor of psychology at Ulster University and a specialist in statistical analysis and epidemiology. He was PI of the NI Study of Health and Stress and the NI Suicide Study.
Dr. Colette Corry, developed the NI suicide database and is currently employed as a research officer at the National Suicide Research Foundation.
Dr. Sam Murphy is a Lecturer in psychology at Ulster University. He is also a chartered ergonomist and coordinator of the NI Study of Health and Stress.
Tony Benson is a doctoral student at Ulster University, specializing in mental disorder treatments. He coded, developed and analyzed the medication and services section of the NI Study of Health and Stress.
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