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Prospective prediction of suicide in a nationally representative sample: religious service attendance as a protective factor

  • Evan M. Kleiman (a1) and Richard T. Liu (a2)
Abstract
Background

Previous research into religious service attendance as a protective factor against suicide has been conducted only retrospectively, with psychological autopsy studies using proxy informants of completed suicide, rather than prospectively, with completed suicide as a dependent variable.

Aims

To determine whether individuals who frequently attended religious services were less likely to die by suicide than those who did not attend so frequently.

Method

We analysed data from a nationally representative sample (n = 20 014), collected in the USA between 1988 and 1994, and follow-up mortality data from baseline to the end of 2006.

Results

Cox proportional hazard regression analysis indicated that those who frequently attended religious services were less likely to die by suicide than those who did not attend, after accounting for the effects of other relevant risk factors.

Conclusions

Frequent religious service attendance is a long-term protective factor against suicide.

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Copyright
Corresponding author
Evan M. Kleiman, Department of Psychology, George Mason University, Mail Stop 3F5, Fairfax, Virginia 22030, USA. Email: ekleiman@gmu.edu
Footnotes
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See editorial, pp. 254–255, this issue.

Declaration of interest

None.

Footnotes
References
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Prospective prediction of suicide in a nationally representative sample: religious service attendance as a protective factor

  • Evan M. Kleiman (a1) and Richard T. Liu (a2)
Submit a response

eLetters

Nothing in Between: a Multi-Faith Psychiatric Response to Kleiman and Liu's Paper on Religion and Suicide

Samuel C Yates, Psychiatry Specialist Registrar
16 May 2014

As a Liberal Jewish Psychiatry Registrar and a moderately observant Hindu Psychiatry SHO, we read with great interest Kleiman and Liu's [1] fascinating paper on the relationship between religious service attendanceand suicide risk. We were also pleased to note that the paper has already generated sufficient interest to give rise to a fascinating editorial by Dr Christopher Cook [2] as well as helpful correspondence between the authors and Pf Nebhinani [3]. This appears to attest to the importance of this topic, and we hope that our additional reflections on the methodologyof Kleiman and Liu's study can be part of an evolving dialogue around the interactions between mental health and religion/spirituality.

Firstly, while, as has been noted, there are many advantages to the prospective study design, difficulties are produced when the outcome of interest (here, completed suicide) is a relatively rare one. Only twenty-five completed suicides occurred, and the absolute numbers occurring in the two groups (frequent versus less frequent service attenders) were not specified. Even a very small 'swing' in the distribution of the suicides from one group to the other could significantly alter the apparent magnitude of the protective effect of service attendance.

Secondly, the absence of any intermediate data between baseline and the end of the study period makes it difficult to draw conclusions about the potential link between religious service attendance and suicide - hence our title 'Nothing in Between'. During the follow-up period (of 12-18 years), much may have changed in people's lives, behaviours and health.In particular, people's level of religious observance (in the form of service attendance) may well have varied over the study period - as may their mental health. Moreover, there may well be interactions between these two variables. With only two data-points (baseline self-report and adichotomous outcome of suicide/not-suicide), it is impossible to know people's religiosity and mental health across the study period.

Thirdly, this lack of intermediate data may stem from the fact that Klein and Liu's study appears to have 'piggy-backed' onto a separate, pre-existing epidemiological survey [4], the primary objective of which was not the investigation of the relationship between religiosity and suicide.Helpful and convenient as it may have been to make use of pre-existing data, it may be that a study set up specifically to address the research question would offer richer information and allow greater extrapolation and clinical application.

Fourthly, and also in terms of clinical applicability, we would question whether the focus on completed, as opposed to attempted, suicide is necessarily an advantage. As the authors observe, there do appear to bedifferences between the clinical profiles of those who complete, compared to attempt, suicide. However, the two are closely related, with previous suicide attempts a sufficiently well-recognised risk factor for suicide completion that it has been controlled for as a potential confounder in Kleiman and Liu's study, even though it was not found to be 'a significantpredictor of death by suicide'. Moreover, in the clinical setting, suicideattempts are one of the primary risk events of concern, but the study doesnot provide information on how religious service attendance may relate to these - information which could be of considerable relevance for risk assessment.

Given the above reflections, as well as the study limitations identified by the authors, Dr Cook and Pf Nebhinani, we would finally justlike to advise caution against an over-simplistic reading of the article'sheadline finding. In our clinical experience, the relationship between a person's religiosity and their risk of self-harm/suicide can vary considerably. We would therefore urge that clinicians continue to conduct detailed exploration of each patient's individual dynamic risk factors andnot overly centrate on particular population-level static risk factors.

References

(1) Kleiman EM and Liu RT. Prospective Prediction of Suicide in a Nationally Representative Sample: Religious Service Attendance as a Protective Factor. BJPsych 2014, 204:262-266.

(2) Cook CCH. Suicide and Religion. BJPsych 2014, 204:254-255.

(3) Nebhinani N. Importance of Frequent Religious Service Attendance:as a Protective Factor against Suicide. BJPsych 2014 [online]: http://bjp.rcpsych.org/content/204/4/262.full/reply#bjprcpsych_el_55186.

(4) National Center for Health Statistics. Plan and Operation of the Third National Health and Nutrition Examination Survey, 1988-1994. Series 1: Programs and Collection Procedures. Vital Health Stat 1994, 32:1-407.

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Conflict of interest: None declared

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