Can Religion Protect Against Suicide? by articles

ORIGINAL ARTICLE

Can Religion Protect Against Suicide? Michael A. Norko, MD, MAR,*† David Freeman, MD,‡ James Phillips, MD,* William Hunter, MD,§ Richard Lewis, MD,* and Ramaswamy Viswanathan, MD, DMSc||

Abstract: The vast majority of the world's population is affiliated with a religious belief structure, and each of the major faith traditions (in its true form) is strongly opposed to suicide. Ample literature supports the protective effect of religious affiliation on suicide rates. Proposed mechanisms for this protective effect include enhanced social network and social integration, the degree of religious commitment, and the degree to which a particular religion disapproves of suicide. We review the sociological data for these effects and the general objections to suicide held by the faith traditions. We explore how clinicians may use such knowledge with individual patients, including routinely taking a religious/spiritual history. The clinician who is aware of the common themes among the faith traditions in opposition to suicide is better prepared to address religious/spiritual matters, as appropriate, in crisis situations. The clinician who understands the patient's belief system is also better prepared to request consultation with religious professionals when indicated. Key Words: Suicide, religion, spirituality, faith tradition, protective effect (J Nerv Ment Dis 2017;205: 9–14)

uicide is a global public health concern, with more than 800,000 completed suicides per year. In 2012, suicide was the 15th leading cause of death worldwide, accounting for 1.4% of all deaths, and was the second leading cause of death among 15- to 29-year olds (World Health Organization, 2016). In the United States, suicide was the 10th leading cause of death in 2013, with over 41,000 suicides. For 15- to 34-year olds in the United States, suicide is the second leading cause of death (Centers for Disease Control and Prevention, 2015). The suicide rate in the United States has increased 24% from 1999 to 2014, increasing by 2% per year since 2006. Increases have occurred for men and women and in all age groups (Curtin et al., 2016). What is the relation of religion to suicide? Religion is an important part of life around the world. Eighty-four percent of the world population is affiliated with a religious belief structure (Pew Research Forum, 2012). Three quarters of the world population ascribes to either the Dharmic religions (Buddhism and Hinduism) or the Abrahamic religions (Christianity, Islam, and Judaism). Broadly, each of these religions, in its true or accurate teachings, is opposed to suicide; they all consider life to be precious. Hence, it is important to study if and how religion protects against suicide. In this article, we review the literature on the subject, explore possible mechanisms for such protective effects, and discuss the implications for clinicians and researchers.

*Department of Psychiatry, Yale University School of Medicine, New Haven; †Forensic Services, Connecticut Department of Mental Health and Addiction Services, Hartford, CT; ‡Mission Health System, Asheville, NC; §OVL Clinic, South Beach Psychiatric Center, Staten Island; and ||State University of New York Downstate Medical Center, Brooklyn, NY. Send reprint requests to Michael A. Norko, MD, MAR. E‐mail: michael.norko@yale.edu. The authors are members of the Psychiatry and Religion Committee of the Group for the Advancement of Psychiatry, which has approved submission of this manuscript as a GAP product. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/17/20501–0009 DOI: 10.1097/NMD.0000000000000615

RELIGION AS A PROTECTIVE FACTOR Many authors cite religion as a protective factor against suicide (Colucci and Martin, 2008; Dervic et al., 2004; Gearing and Lizardi, 2009; Koenig, 2009; Wu et al., 2015). In a systematic review of quantitative research on religion, spirituality, and depression, Koenig et al. (2001) reported that the majority (61%) of studies reported inverse relationships between religion/spirituality and depression, and very few (6%) reported direct correlative relationships. Although this article focuses on the potential mitigating effects of religion on suicide, we note that religion does not always have this effect. For example, Hindu cultural history includes the acceptance of sati (the burning death of a woman on her husband's funeral pyre) (Bhugra, 2005; Commission, 1987). Suicide is a recognized form of political protest in some Buddhist countries (Tibet and Vietnam) (Worth, 2011). Contemporary suicide bombings are perpetrated under the guise of religious salvation (Anees, 2006). It is also important to note that some individuals may experience dissonance between their personal beliefs and their faith tradition of origin, and this can lead to feelings of anger, guilt, and shame and can adversely affect mental health (Pargament et al., 1998). Elaboration of these topics is beyond the scope of this article.

POSSIBLE MECHANISMS OF PROTECTION There are various mechanisms by which religion may be protective against suicide. The preeminent sociologist Émile Durkheim promulgated the idea that religion is a major integrating, cohesive force in traditional societies (Durkheim, 1951a), and he argued that that force is specifically protective against suicide (Durkheim, 1951b). Although details of Durkheim's study of suicide have been challenged (see the study by Colucci and Martin, 2008, for example), his general argument for the protective effect of religious affiliation is still accepted. Persons residing in nations with relatively high levels of religiosity, associated with one of the four major faiths (Buddhism, Christianity, Hinduism, and Islam), are found to have lower rates of acceptability of suicide (Stack and Kposowa, 2011). Observed suicide rates are higher in countries where religious beliefs are not actively promoted by the state and lower in countries where they are (Neeleman and Lewis, 1999). van Tubergen et al. (2005) also noted that the protective influence of religious groups affects the community as a whole and not just members of particular religious affiliations. Consistent with these findings, researchers have noted a protective effect of attendance at churches (Kleiman and Liu, 2014; Robins and Fiske, 2009; Stack and Lester, 1991; VanderWeele et al., 2016). In contrast, private religious practices, such as prayer, are not protective of suicide, providing evidence that the protective effect is mediated by social support (Robins and Fiske, 2009) and/or the positive effects of social networking within religious communities (Colucci and Martin, 2008; Nelson et al., 2012; Pescosolido and Georgianna, 1989). In addition to the protective effect of religious affiliation, researchers have found that particular beliefs may also be protective (Stack and Kposowa, 2011; Stark et al., 1983). With a belief in the afterlife, for instance, a person who suffers may endure adversity without becoming hopeless, which is a prime risk factor for suicide. The religiously committed individual may not see suicide as an