Commentary: Religion, religious attitudes and suicide

1496 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Research can then inform social policy, clinical practice and legal decisions. Research on this can also guide preventive actions, if we can disentangle the critical factors that either reduce risk or protect against suicide. Conflict of interest: None declared. References 1 2 3 4 5 6 7 8 9 Hawton K, van Heeringen K. Suicide. Lancet 2009;373: 1372–81. O’Carroll PW. A consideration of the validity and reliability of suicide mortality data. Suicide Life Threat Behav 1989; 19:1–16. McKenzie K, Bhui K, Nanchahal K, Blizard B. Suicide rates in people of South Asian origin in England and Wales: 1993–2003. Brit J Psychiatry 2008;193:406–9. Durkheim E. Suicide: A Study in Sociology, 1951 (1897), Translated by John A. Spaulding & George Simpson, The Free Press of Glenco: New York. Reprint 1997. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a review. Rev Bras Psiquiatr 2006;28:242–50. Bhui KS, McKenzie K. Rates and risk factors by ethnic group for suicides within a year of contact with mental health services in England and Wales. Psychiatr Serv 2008; 59:414–20. Bhugra D. Sati: a type of nonpsychiatric suicide. Crisis 2005;26:73–7. Bystrisky A. Classical mindfulness: an introduction to its theory and practice for clinical application. Ann N Y Acad Sci 2009;1172:148–62. Spoerri A, Zwahlen M, Bopp M, Gutzwiller F, Egger M. Religion and assisted and non-assisted suicide in Switzerland. A National Cohort Study. Int J Epidemiol 2010;39:1486–94. Published by Oxford University Press on behalf of the International Epidemiological Association ß The Author 2010; all rights reserved. International Journal of Epidemiology 2010;39:1496–1498 doi:10.1093/ije/dyq232 Commentary: Religion, religious attitudes and suicide Dinesh Bhugra Health Service & Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. E-mail: Accepted 28 October 2010 Introduction Religion may play a significant role in the identity of an individual. A key component of an individual’s culture, religion can act both as a protector against emotional distress and also as a precipitant. The relationship between religion and spirituality on the one ago; there is also a higher risk of suicide amongst men with no religious affiliation compared with men with a religious affiliation. These data suggest, whether one believes or not in a particular religious teaching, that religious people do think differently about the meaning of life and tend to be more reluctant to consider suicide (assisted or not) as an option. Secondly, consistent with previous research, these effects are more powerful among the elderly, in whom there is a higher risk of suicide; and among women compared with men. Thirdly, the study included those taking their lives through assisted suicide. This is especially important, as it shows that trends found for unassisted suicide are also found in assisted suicide. The constraints affecting decisions to take one’s life in both situations may actually reflect individual and group predispositions for suicide including beliefs about the meaning and purpose of life; individual and group resiliency factors including religiosity; and styles of thinking that conclude suicide is a logical and rational option or not an option. This is where religious beliefs and practices, cultural beliefs and practices, individual and group processes emerge as relevant and influential factors. This study therefore suggests that the constraints and risk factors in assisted suicide are not that different from the unassisted suicide population.9 We need to understand the cultural underpinnings of suicidal behaviour and thinking, attitudes to the meaning of life and what value we place on life and at what cost. The role of age, gender, religious affiliations and practice show consistent and strong associations with suicide. Investigations of environmental, personality and biological vulnerabilities should take place alongside investigations of resiliency factors. RELIGION, RELIGIOUS ATTITUDES AND SUICIDE Religion and suicide Rates of suicide and suicidal behaviours vary across countries and have also changed over centuries. These variations are related to a number of factors in reporting; for example, in countries where the act of suicide is punishable by law, the reported rates are likely to be lower. Social factors, such an anomie3 and unemployment, are likely to be related to rates of suicide. Personal and individual factors, such as gender, age, social status, religion and other socio-demographic factors, may also play a role. The relationship between age and gender in understanding the process of suicide and suicidal behaviour is well-recognized across cultures. As religion and religious values play a key role in attitudes to depression and suicide, but not all cases of suicide suffered from depression,4 an interesting interaction between suicide, depression and religion, along with capacity and consent, starts to emerge. As noted above, religion can play a key role in protecting individuals. Dervic et al.5 found that suicidal attempts among depressed patients were less likely in patients who had religious affiliations compared with those who did not. Religious affiliations per se may mean many things, and thus need to be differentiated from beliefs, rituals and attitudes as well as from religiosity. Religiosity has been seen as a normal constituent of human behavioural repertoire.6 In religions such as Hinduism (which is more than just a religion, but also a philosophy and a way of life), where life is seen as a cycle and reincarnation is seen as part of this cycle, attitudes to suicide may be more liberal. However, in India, the suicidal act remains punishable by law. In Islam, on the other hand, self-harm and suicide are prohibited, indicating that rates would be expected to be low.7 However, under these circumstances, a disclosure of suicidal thought and ideation may be artificially lower. In Christianity, attitudes to suicide vary. In the Middle Ages, the clergy believed that suicide occurred as a result of the temptations by the Devil.8 Suicides were buried at a distance from the community and their bodies pierced with a stake to offer protection against their malevolent souls. Over the centuries, attitudes towards suicide changed and the proportion attributed to mental illness increased.9 Retterstøl and Ekberg,10 in a comprehensive review, note that some changes have occurred in the understanding of mental suffering and attitudes of the Catholic and Orthodox churches (for example, although suicide is proscribed, the previous practice of refusal to bury and punishment have been abandoned). They highlight that a restrictive attitude to suicide in a population may increase the threshold for such acts, but, if the taboos are too strict, people who need help may not ask for it. Dependin (...truncated)