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Separation as an Important Risk Factor for Suicide: A Systematic Review

Naoko Ide, Marianne Wyder, Kairi Kolves and Diego De Leo Journal of Family Issues 2010 31: 1689 originally published online 26 March 2010 DOI: 10.1177/0192513X10365317 The online version of this article can be found at: http://jfi.sagepub.com/content/31/12/1689

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Separation as an Important Risk Factor for Suicide: A Systematic Review

Naoko Ide1, Marianne Wyder1, Kairi Kolves1, and Diego De Leo1

Journal of Family Issues 31(12) 16891716 The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/0192513X10365317 http://jfi.sagepub.com

Abstract Examining how different phases of relationship separation effects the development of suicidal behaviors has been largely ignored in suicide studies. The few studies conducted suggest that individuals experiencing the acute phase of marital/de facto separation may be at greater risk of suicide compared with those experiencing long-term separation (divorce). To clarify the effects of these factors on detection and prevention of suicidal behaviors, a critical review of the English-language literature on this topic from 1966 to 2008 was undertaken. No studies reliably indicate the impacts of acute separation versus long-term divorce on suicidality. Moreover, research has not specifically addressed the interaction between the psychosocial factors influencing suicidal behaviors in the context of a marital/de facto separation. Considering the large proportion of suicides that occur in the context of marital/de facto separation, our limited understanding of the factors involved in the development of these suicidal behaviors is of concern. Keywords separation, divorce, marital status, suicide, suicide attempt

Griffith University, Mt Gravatt, Queensland, Australia

Corresponding Author: Diego De Leo, AISRAP, Mt Gravatt Campus, Griffith University, 176 Messines Ridge Road, Mt Gravatt, Queensland 4122, Australia Email: D.Deleo@griffith.edu.au

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Although there is much empirical evidence to suggest that suicide rates are higher among divorced individuals compared with the general population (e.g., Cheung, 2000), few studies have investigated the impact of relationship separation on the development of suicidal behaviors. These investigations have suggested that separated people would face a greater risk of suicide compared with divorced (Cantor & Slater, 1995; Torre et al., 1999). Although separation from a partner as an acute life event has been reported as an important factor in predicting suicide (Heikkinen, Aro, & Lonnqvist, 1992, 1994; Kolves, Sisask, Anion, Samm, & Varnik, 2006; Kolves, Varnik, Schneider, Fritze, & Allik, 2006), the possibly different impact of separation (acute separation) and divorce (long-term separation) on suicidality has been largely ignored in current suicidological literature. Furthermore, there is very little knowledge of the underlying structural/systemic, social and psychological factors that may increase the risk of suicidal behaviors in the context of separation. Very few studies actually distinguish between separated and divorced. The majority of studies investigating marital status in relation to suicidal behaviors classify separated people within either single or married status categories or combine separated and divorced subjects together in one category. Even among the studies that distinguished between separated and divorced, only two offered an operational definition of separation (Conner, Duberstein, & Conwell, 2000; Jacobson & Portuges, 1978). Therefore, it is difficult to know what particular phase of their separation process these individuals were experiencing at the time of their suicide. When one considers that a large number of separations occur in many Western countries (Carmichael, Webster, & McDonald, 1997) and that many cases of suicide occur in the context of such processes (De Leo, Klieve, & Milner, 2006), a deeper understanding of the different phases of the separation process and the identification of critical factors consequently associated with suicide could have a powerful impact on reducing suicide rates (Cantor & Slater, 1995; Cheung, 2000; Stack, 2000). This review of the literature has been undertaken to understand the possible role of separation on fatal and nonfatal suicidal behaviors.

Method
The electronic databases MEDLINE, PSYCHLIT, and SCOPUS were searched and literature sourced from 1966 to 2008. The search retrieved Englishlanguage articles containing the following key terms: (a) suicide and suicidal behavior (including suicide ideation, suicide attempt, deliberate self-harm and

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parasuicide); and (b) marital/cohabitant separation (including marital status, relationship or marital/de facto/cohabitant relationship breakdown, dissolution). All abstracts were reviewed and potentially relevant references retrieved, and reference lists scanned for further possible articles. Identified studies were then appraised with regards to the following selection criteria: 1. 2. 3. study outcomes focused on separation or divorce in relation to suicidal behavior, source of suicide data was clearly stated and reliable, and studies were controlled for other variables to analyze individual contributions of separation or divorce on suicide risk.

A total of 52 articles were selected. Of these, only 13 articles used separation as an independent category, 10 studies categorized separated and divorced together; and the rest of the studies (29) only used divorce status to examine suicide risk. Results of these articles were reviewed with particular focus on the development of suicidal behaviors during the separation process.

Results Marital Status and Suicidal Behaviors

Table 1 presents a summary of 14 studies (from 13 published articles) that examined the likelihood of developing suicidal tendencies in people going through relationship separation. Durkheim (1897/1951) stated that marriage is protective against suicide as it increases social integration. Conversely, dissolution of marriage increases the risk of suicide as it breaks the bonds of social integration and deviates from social norms (Durkheim, 1987/1951). Durkheims hypotheses have been mostly tested with an ecological study design, using aggregated levels of data on rates of suicide and official classifications of marital status, which traditionally did not include separated status. Consequently, although the impact on suicide of the separation phase (which precedes divorce) cannot be seen from these studies, many of these early observations found that suicide rates are lower among married people and higher among divorced people, specifically in countries such as Australia (Lorant, Kunst, Huisman, Bopp, & Mackenbach, 2005; Ruzicka & Choi, 1993), Belgium (Lorant et al., 2005), Canada (Leenaars & Lester, 1998, 1999; Trovato, 1986, 1991), Czech Republic (Dzurova, Ruzicka, & Dragomirecka, 2006), England and Wales (Griffith, Ladva, Brock, & (text continues on p. 1700)

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Study Design (Measures if Applicable) Category Marital status (married, never married, divorced, separated, widowed) Main Findings Male suicide: Separated had a SMR 6.2 times higher than married and divorced had SMR 0.5 times less than separated Female suicide: Divorced had a SMR 2 times higher than separated, which showed 1.6 times higher SMR compared with married Calculation of the suicide rates on marital status showed that separated for both sex were the highest risk group compared with other marital status Separated males were 5 times more at risk and separated females were 7 times more at risk of suicide compared with divorced counterparts Marital status (single, married, widow, separated, divorced, cohabitant) (continued)

Table 1. Studies Examining the Association Between Separation and Suicidal Behavior

Study

Suicidal Behavior

Country and Target Population

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Acute separation versus long-term separationFatal suicidal behavior Ecological study Fatal suicidal Queensland, Australia Cantor behavior The Queensland and Health Suicide Slater Register (1990-1992) (1995) Male suicides: n = 1,083 Female suicides: n = 292 Population data from Australian Bureau of Statistics (1993) Ecological study Fatal suicidal Turin, Italy Torre behaviors The office of et al. examining (1999) Magistrates of the Court of Justice (1988-1994) Male suicides: n = 1,153 Female suicides: n = 518 Population data from the Italian Census (1994)

Table 1. (continued)

Study Marital status (unmarried, married, cohabitants, widow, separated, and divorced) Groups defined by stages of separation 1. person seriously discussing separation/ divorce 2. Persons who recently separated/ divorced 3. Persons who were in a longterm separation or divorce

Suicidal Behavior Category Main Findings

Country and Target Population

Study Design (Measures if Applicable)

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Acute separation versus long-term separationNonfatal suicidal behavior Cross-sectional Baerum, Norway Nonfatal Dieserud study Local general hospital suicidal et al. (1984-1995) behavior (2000) Male suicide attempts: Suicide n = 371 attempts Female suicide attempts: n = 660 Cross-sectional Los Angeles, USA Nonfatal Jacobson study The Benjamin Rush suicidal and Center, the Crisis behavior Portuges Intervention Suicidality (1978) Division, Los Angeles Suicidality Center users had assessed by seriously discussed the Suicidal about issues related Prevention to marital separation Centre within the previous Assessment 13 months. of Suicide Users were either not Potential yet separated or separated/divorced n = 238

The highest risk of engaging in suicide attempts was among separated males compared with married ones (relative risk = 3.6), and among divorced females compared with the married ones (relative risk = 3.4) Serious discussion of separation/divorce group was significantly less likely to be suicidal than the other two groups (p < .05) Recent separation group was slightly more suicidal than the divorced one; however, there was no statistical difference between the groups (p = NS)

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Study Design (Measures if Applicable) Category Marital status (married, cohabiting, single, widowed, divorced, separated) Marital status (single, married, widow, separated, divorced, cohabitant) Main Findings Separated had the highest risk of suicidal thoughts (OR = 4.37, 95% CI =2.78-6.89), followed by divorced (OR = 2.73, 95% CI = 1.88-3.96) compared with the married group Cross-sectional study The Revised Clinical Interview Schedule Ecological study Calculation of the suicide attempts rates on marital status showed that separated for both sexes were the highest risk group for attempted suicide compared with other marital status Approximately, separated males were 6 times more at risk and separated females were 5 times more at risk compared with divorced people (continued)

Table 1. (continued)

Study

Suicidal Behavior

Country and Target Population

Thomas et al. (2002)

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Torre et al. (1999)

Nonfatal suicidal behavior Suicidal thought: life was not worth living in the past 7 days Nonfatal suicidal behavior Suicide attempts

Great Britain The Office of Population Censuses and Surveys (1993) Suicidal thoughts: n = 346 Nonsuicidal thoughts: n = 9,484 (not gender specific) Turin, Italy The office of examining Magistrates of the Court of Justice (1988-1994) Male suicide attempts: n = 537 Female suicide attempts: n = 498 Population data from the Italian Census (1994)

Table 1. (continued)

Study Cross-sectional study Acute life events St. Paul Ramsey Life Experience Scale (Roy, Pickar, Linnoila, Doran, & Paul, 1986) Chronic life events Spanish version of Adjustment Scale (Holmes & Rahe, 1967) Matched casecontrol psychological autopsy study Life events during the past 3 months Acute life events during the last 2 months Partner conflicts Chronic life events during the last 2 years Separation/divorce Partner arguments

Suicidal Behavior Category Main Findings

Country and Target Population

Study Design (Measures if Applicable)

Separation from partner as an event Madrid, Spain Baca-Garcia Nonfatal Emergency service suicidal et al. of the behavior (2007) Ramon y Cajal Suicide Hospital attempts Suicide attempts: n = 258 Nonsuicide attempts: n = 325

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Kolves, Sisask et al. (2006)

Fatal suicidal behavior

Estonia Psychological autopsy study in Estonia (1999)

Acute life events, suicide attempters experienced partner conflict significantly more (52%) than nonattempt group (5%) (OR = 18.8, CI = 10.9-32.3) during the last 2 months Chronic life events, attempters experienced separation or divorce within the past 2 years (23%) significantly more than nonattempt group (3%; OR = 8.2, CI = 4.2-16.1). Partner arguments was the most frequently reported event among attempters (36%) and was statistically more frequent compared with nonsuicide attempts (2%; OR = 29.4, CI = 12.5-66.7) 18.9% of Estonian suicides and 14.0% of Russian Estonian suicides experienced separation 3 months prior to their suicide (continued)

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Study Design (Measures if Applicable) Category Separation from partner Family discord Main Findings Recent Life Change Questionnaire (Rahe, 1977) with modifications from the list of Paykel et al. (1969) Matched casecontrol psychological autopsy study (gender, age, nationality matched living control) Life events during the past 3 months Separation from partner Family discord Suicide victims of both Estonian and Russian Estonians were more likely to experience separation than control group (Estonians, OR = 4.1, 95% CI = 1.9-8.9; Russians, OR = 11.0, 95% CI = 3.4-35.9) Final conditional logistic regression model showed that separation among Russian Estonians (OR= 32.3, CI = 2.9-364.1, p < .005) and family discord (OR = 4.5, CI = 2.19.8) for Estonians were significant factors associated with suicide 15.5% of Tallinn suicides and 7.4% of Frankfurt suicides experienced separation 3 months prior to their suicide Separation from partner represented a strong risk factor for suicide in both cities (Tallinn, OR = 12.0, CI = 3.0-104.8; Frankfurt, OR = 4.0, CI = 1.1-22.1) (continued)

Table 1. (continued)

Study

Suicidal Behavior

Country and Target Population

Suicide cases: n = 427 Gender, age, nationality matched living control n = 427

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Kolves, Varnik, et al. (2006)

Fatal suicidal behavior

Tallinn, Estonia, and Frankfurt, Germany Psychological autopsy study in Tallinn and Frankfurt (1999) Tallinn Suicide cases: n = 159 Gender, age, nationality matched living control: n = 159

Table 1. (continued)

Study

Suicidal Behavior Category Main Findings

Country and Target Population

Study Design (Measures if Applicable)

Frankfurt Suicide cases: n = 163 Gender, age, and living area matched control: n = 163

Final conditional logistic regression model showed that separation among Frankfurt suicides (OR = 5.3, CI = 1.4-20.6, p < .05) and family discord (OR = 25.2, CI = 6.0-105.5, p < .0001) among Estonians were risk factors associated with suicide in both cities Life events during the past 3 months Separation from partner Family discord Partner informants perception of precipitated events The partner informants perceived separation as the most significant recent life events that precipitated suicide (69% of the sample) Separation and family discord were more commonly reported by younger man than older man (p < .01 and p < .001) whereas for female, no significant age difference found for occurrence of these events

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Heikkinen et al. (1992)

Fatal suicidal behavior

Finland The National Suicide Prevention Project (April 1987 to March 1988) Male suicides: n = 316 Female suicides: n = 84

Recent Life Change Questionnaire (Rahe et al., 1977, with modifications from the list of Paykel et al., 1969) Psychological autopsy study (partner as informant) Recent Life Change Questionnaire (Rahe, 1977, with modifications from the list of Paykel et al., 1969)

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(continued)

Table 1. (continued)

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Study Design (Measures if Applicable) Category Life events during the past 3 months Separation from partner Family discord Main Findings 14% of Finland suicides experienced separation from partner 3 months prior to their suicide Psychological autopsy study (partner as informant) Recent Life Change Questionnaire (Rahe, 1977, with modifications from the list of Paykel et al. 1969) Psychological autopsy study Life events Conflict, separation and rejection Life events during the past 12 months Separation from partner Cross-sectional study The most frequently reported stressful event was conflict separationrejection across all age groups, except the 40-49 years age group Separation from partner was the most rated significant life event among suicide attempters, which showed statistically significant difference compared to nonsuicide attempt group (p < .001) (continued)

Study

Suicidal Behavior

Country and Target Population

Heikkinen et al. (1994)

Fatal suicidal behavior

Finland The National Suicide Prevention Project (April 1987 to March 1988) Nationwide suicide population N = 1,067

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Rich et al. (1991)

Fatal suicidal behavior

Wasserman (1988)

Nonfatal suicidal behavior Suicide attempts

San Diego, USA The San Diego Suicide Study Male suicides: n = 137 Female suicides: n = 58 Sweden Psychiatric institutions in a catchment area in a 2-year period Male suicide attempts: n = 49

Table 1. (continued)

Study Relationship problems with partner

Suicidal Behavior Category Main Findings

Country and Target Population

Study Design (Measures if Applicable) Relationship problems was the second most traumatic event reported by attempters, and the difference between the groups was statistically significant (p < .05)

Female suicide attempts: n = 86 Male nonsuicide attempts: n = 1,193 Female nonsuicide attempts: n = 1,536 Casecontrol psychological autopsy study Separated and nonseparated Separation defined as formally cohabitating couple living apart at the time of suicide with the separation occurring in the past year, or legal separation/ divorce with in the year

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Other variables Fatal suicidal Conner behavior et al. (2000)

St. Louis County, USA The Counseling for Alcoholics Marriage Project (1968-1970) Male alcoholic suicide: n = 40 Partner violent: n = 20 Nonpartner violent: n = 20

20% of alcoholic suicide males were separated from their partner at the time of suicide Men with domestic violence were more likely to be separated from their partner at the time of suicide (p = .04) and had earlier age onset of alcoholism (p = .03)

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Note: SMR = standardized mortality ratio; NS = nonsignificant; OR = odds ratio; CI = confidence interval.

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Baker, 2008), Finland (Lorant et al., 2005), Korea (Kim et al., 2006; Park & Lester, 2006), Italy (Lorant et al., 2005), and the United States (Chuang & Huang, 1996; Cutright & Fernquist, 2004; Gibbs, 2000; Gove, 1972; Kposowa, 2000; Kposowa, McElvain, & Breault, 2008; Leenaars & Lester, 1995; Lester & Yang, 1991; Smith, Mercy, & Conn, 1988; Stack, 1981; I. M. Wasserman, 1984). Despite these empirical findings, research conducted in Asian countries such as China (Yip, 1998), Japan (Stack 1992) and Taiwan (Chuang & Huang, 1996) found no association between divorce and suicide rates after controlling for other social variables. However, this evidence has been contradicted by a recent study in Taiwan (Chuang & Huang, 2007). Whereas some investigations found that divorce predicted suicide in both genders (Kim et al., 2006; Leenaars & Lester, 1998; Ruzicka & Choi, 1993; Trovato, 1991), other studies found that divorced males were at a greater risk of suicide than females (Kposowa, 2000), with the risk being particularly apparent among middle and old-age males (Gibbs, 1969; Griffith et al., 2008; Gunnell, Middleton, Whitley, Dorling, & Frankel, 2003; Kreitman, 1988; Luoma & Pearson, 2002; Smith et al., 1988; Trovato, 1986). Studies that combined divorced and separated as one marital status category also found a significant association with suicide (Iribarren, Sidney, Jacobs, & Weisner, 2000; Trovato, 1991). The separated/divorced group was twice as likely to commit suicide compared with those who were married (Kposowa, 2000, 2003; Kposowa et al., 2008). Suicide ideation is common in the divorced (Arensman, Kerkhof, Hengeveld, & Mulder, 1995) and the combined divorced and separated cluster (Weissman et al., 1999). These groups are overrepresented among suicide attempters compared with other marital status groups (Arensman et al., 1995; Petronis, Samuels, Moscicki, & Anthony, 1990; Weissman et al., 1999). Other studies reported people categorized as single having the highest risk of developing suicide attempts (Iribarren et al., 2000; Lhr & Schmidtke, 2004), and evidence that has also been found in people categorized as either single or separated/divorced (Kjller & Helweg-Larsen, 2000; D. Wasserman et al., 1994). The aforementioned studies clearly indicate that marital dissolution is an important risk factor in both fatal and nonfatal suicidal behaviors. However, these studies do not distinguish between divorced and separated as different states, so these macro-level findings cannot identify which phase of marital/de facto separation increases the risk of suicidal behaviors.

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Separation Versus Divorce

As presented in Table 1, only two studies distinguish between separation and divorce in relation to suicide rates. Both studies found that separated people had the highest risk of suicide compared with other marital status categories (Cantor & Slater, 1995; Torre et al., 1999). In Australia, Cantor and Slater (1995) found that the rate of suicide among separated males was two times higher than divorced males and 6.2 times higher than married males. Conversely, separated females were found to be two times less prone to suicide than women who were divorced. A comparison by gender shows that whereas divorced males and females share a similar risk of suicide, separated males are almost four times more likely to suicide than separated females. However, in Italy, Torre et al. (1999) found that separated males and females had the highest risk of suicide, followed by those who were widowed. This study found that the risk of suicide in separated males was five times higher than in divorced males, whereas separated females were almost seven times more likely to suicide than divorced females. Similar to studies on fatal suicidal behavior, separated individuals were found to have a higher risk of developing nonfatal suicidal behavior than divorced individuals (Dieserud, Loeb, & Ekeberg, 2000; Thomas, Crawford, Meltzer, & Lewis, 2002; Torre et al., 1999). A study in Norway (Dieserud et al., 2000) found that separated males had the highest risk of attempting suicide, followed by single males, with a relative risk (RR) 3.4 times higher than married males. The same study found that divorced women were most likely to attempt suicide (431 per 100,000), followed by separated women (331 per 100,000). In Italy (Torre et al., 1999), suicide attempts were six times more likely to be performed by separated males and five times more likely by separated females when compared with their divorced counterparts. An early study by Jacobson and Portuges (1978) concentrated on different phases of the marital separation process and their subsequent impact on suicidality. They divided participants into the following categories: (a) those discussing separation/divorce but not yet separated, (b) those recently separated, and (c) subjects with a long-term separation/divorce. Findings from this study indicated that individuals engaged in the discussion process, before the actual separation, had a significantly lower risk of developing suicidal behavior. The recently separated group had a higher risk of developing suicidal behavior when compared with long-term separated and divorced group; however, the difference did not reach statistical significance. A study in Great Britain focusing on separation and suicidal thoughts (Thomas et al., 2002)

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found that separated individuals had the highest risk of developing suicidal thoughts (odds ratio [OR] = 4.37, 95% confidence interval [CI] = 2.78-4.33), followed by divorced individuals (OR = 2.73, 95% CI = 1.88-3.96). Interpretation of the findings from all studies mentioned in this section requires caution, because the separated category was only operationally defined as a process by Jacobson and Portuges (1978). No other studies provide information as to which phase of the separation process individuals were experiencing at the time of engaging in their suicidal behaviors. The social context in which a given research is conducted also deserves consideration. For example, Torre et al.s (1999) study was carried out in Italy, where Catholicisms strong influence means that fewer people end by legally divorcing, with marital dissolution more likely to take the form of a marital separation lasting indefinitely. Therefore, those who were categorized as separated in that study could not be all experiencing an acute phase of separation. In Australia, Cantor and Slaters (1995) study analyzed the Queensland Health Suicide Register data in which marital status is reported by police officers based on next-of-kin postmortem interviews. Although many police reports documented a recent separation experienced by the deceased, in 50% of cases the marital status at the time of death was not reported. The researchers then needed to use the Queensland Register on General Causes of Death, which did not include the separated category. Therefore, the true impact of separation may have been underestimated. In the study by Jacobson and Portuges (1978), a clear definition of the separation process was provided; however, the participants were recruited from a Crisis Intervention Centre. Then, it is likely that the participants who were classified as long-term separated or divorced were still experiencing high levels of distress. If so, this could explain the nonsignificant difference in terms of suicidality between the acute and the long-term separation groups.

Separation as a Life Event Triggering Suicidal Behaviors

There have been several studies on significant life events and their association with the development of suicidal behaviors. Findings from these studies indicate that recent separation from a partner is an important factor in predicting the development of suicidal behaviors (Heikkinen et al., 1992; Kolves, Sisask, et al., 2006; Kolves, Varnik, et al., 2006; Rich, Warsradt, Nemiroff, Fowler, & Young, 1991). Four psychological autopsy studies focused particularly on the inclusion of separation from a partner as an important life event. In Finland, Heikkinen et al. (1992) interviewed longterm partners of suicide victims regarding the significant life events occurred

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in the 3 months before the suicide and found that separation was the most critical precipitating event reported in both men (69%) and women (60%). Psychological autopsy studies that investigated significant life events in the past 3 months of the deceaseds life in Germany, Finland, and Estonia indicated that separation from a partner was a major risk factor, with the proportion of suicide victims who experienced separation ranging from 7% in Germany (Kolves, Varnik, et al., 2006) to 14% in Finland (Heikkinen et al., 1994) and 16% in Estonia (Kolves, Varnik, et al., 2006). Suicide victims were significantly more likely to experience separation from a partner compared with the nonsuicide control group (Kolves, Sisask, et al., 2006; Kolves, Varnik, et al., 2006). Furthermore, in the United States, Rich et al. (1991) found that, apart from the 40- to 49-year-old group, separation was the most common stressor experienced by the deceased prior to suicide (no specific time frame provided) across all other age spans for both genders. Two studies have investigated the relationship between separation and the development of nonfatal suicidal behaviors. In Sweden, D. Wasserman (1988) investigated recent significant life events associated with suicide attempts and found that separation from a partner was the most highly rated significant event among suicide attempters compared with nonattempters (p < .001). Interestingly, in her study, she also examined the marital status data (unmarried, married, divorced, and widowed), but found no significant differences between the various marital status categories. In Spain, a study found that suicide attempters experienced separation or divorce in the 2 years prior to their nonfatal attempts significantly more frequently when compared with suicide nonattempters (23% and 3%, respectively; Baca-Garcia et al., 2007).

Association Between Divorce or Separation, Suicidal Behaviors, and Other Variables

Overall, the impact of separation/divorce on suicidal behaviors has proven to be independent from various socioeconomic and demographic factors such as race, income, education, migration, religion, and alcohol consumption (Cutright & Fernquist, 2004; Kposowa, 2000, 2003; Kposowa et al., 2008; Lorant et al., 2005; Stack & Wasserman, 1993; Trovato, 1986; D. Wasserman et al., 1994). However, studies on nonfatal suicidal behavior found that, for example, divorce directly affected depression, which then sequentially related to subsequent suicide attempts (Dieserud, Roysamb, Braverman, Dalgard, & Ekeberg, 2003). Furthermore, divorced suicide attempters were significantly more dissatisfied with their social interactions compared with other marital status groups (Magne-Ingvar, Ojehagen, & Traskman-Bendz,

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1992). Conner et al. (2000) examined the association between alcoholism, domestic violence, and marital separation within a year from suicide. They found that men with a history of domestic violence were more likely to have separated from their partner within the year before suicide, and had an earlier onset of alcoholism. As it can be seen, there is a lack of studies that reliably report on the differences in suicide risk between short- and long-term separations. Additionally, research examining the social and psychological suicide risk factors within the context of marital separation is extremely limited. This is of concern, because suicidal behavior is often preceded by a relationship separation. From these findings, it is not possible to clearly understand how separation interacts with the social and individual factors leading to suicidal behaviors.

Methodological Problems
There are a number of limitations that should be noted when interpreting the results described above. First, the most important issueidentified across the majority of studiesis the classification of marital status. Most studies allocate separated individuals to either the categories of married or single. Therefore, being married includes people who are either legally separated or living apart with the intention of obtaining divorce or permanently/ temporarily separated because of marital discord. Furthermore, there are an increasing number of de facto relationships instead of registered marriage. For example, in Australia the number of de facto relationships (cohabiting but not legally married) rose from 951,500 to 1,193,400 between 2001 and 2006an increase of 25% (Australian Bureau of Statistics, 2008). De facto relationships tend to be less stable than marriage: It was estimated that only 9% of de facto relationships commenced in the 1990s were still intact in 2001 (Australian Institute of Family Studies, 2006). Consequently, the rate of separations is likely to be generally underestimated. Studies investigating the different phases of the separation process are very few. Although Conner et al. (2000) and Jacobson and Portuges (1978) provided operational definitions for different phases of the separation process, their findings may have been confounded by the peculiarity of their selection methods, which used samples not representative of the general population (e.g., crisis centers attendees). Another important limitation is that many of the studies reviewed analyzed data at the macro level (Chuang & Huang, 1996, 2007; Cutright & Fernquist, 2004; Dzurova et al., 2006; Gibbs, 1969, 2000; Gunnell et al.,

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2003; Leenaars & Lester, 1995, 1998, 1999; Lester & Yang, 1991; Park & Lester, 2006; Stack, 1981; Stack 1992; Trovato, 1986; I. M. Wasserman, 1984). However, this method of analysis can lead to ecological fallacy (Robinson, 1950), as it remains uncertain whether divorced people have really contributed toward the elevation of suicide rates. In fact, elevated rates may instead be because of suicide committed by other marital status subgroups within areas where divorce rates are high (Trovato, 1991). On the other hand, ecological studies that focused on suicide risk by using marital statusspecific suicide data (Griffith et al., 2008; Kim et al., 2006, Kposowa, 2000, 2003; Kposowa et al., 2008; Kreitman, 1988; Lorant et al., 2005, Luoma & Pearson, 2002; Ruzicka & Choi, 1993; Smith et al., 1988; Trovato, 1991) were compounded by the problems with the categorization of marital status mentioned above (Breault, 1994; I. M. Wasserman, 1984).

Limitation of the Current Study

Systematic reviews, including the current one, usually involve a publication bias (Hawton, Sutton, Haw, Sinclair, & Deeks, 2005). This refers to the fact that only articles reporting significant results may have been accessible, whereas other studies involving nonsignificant findings may have been unintentionally excluded. Another issue is that the methodologies of studies on marital/de facto separation and suicide vary extensively because of different theoretical approaches. These can range from the macro level (sociological approach) to the micro level (individuals). Because many of the studies focused on the macro level, information concerning acute separation and long-term separation, as well as other potentially influential variables, was very limited. Furthermore, the lack of an operational definition of separation created further difficulties when analyzing the risk of acute and long-term separation on suicidality.

Discussion
On the aggregated data level, findings from numerous studies have identified that married people are less likely to commit suicide, whereas divorced people are more vulnerable to suicide, particularly in Western countries. This association between marital status and suicide is one of the strongest supports for Durkheims social integration theory (Stack, 2000). The social context in which the separation occurs and its influence on individual experiences have an impact on the varying patterns of divorced suicide rates in different genders, ages, and cultures. This indicates that suicidal behaviors do

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not have a unidimensional meaning across different social groups and societies (Douglas, 1968). As shown, very few studies have investigated the process of separation on the development of suicidal behaviors. However, it appears that during the acute stage of separation there is a higher risk of suicide, particularly in males (Cantor & Slater, 1995). Moreover, studies on life events experienced 3 months prior to suicide suggested that recent separation from a partner was a significant risk factor for suicide (Heikkinen et al., 1992, 1994; Kolves, Sisask, et al., 2006; Kolves, Varnik, et al., 2006). Relationship difficulties in general have also been reported as an important precipitating factor of suicidal behaviors (Appleby, Cooper, Amos, & Faragher, 1999; De Leo, Cerin, Spathonis, & Burgis, 2005; Kjller & Helweg-Larsen, 2000; Lhr & Schmidtke, 2004; D. Wasserman et al., 1994). It is also important to note here that all studies reviewed in this article did not distinguish between early divorcees and long-term divorcees. Consequently, the true impact of early divorce may be confounded in these studies. A study found that males who have divorced within 1.5 years are particularly at risk of suicide (Bojanovsky, 1979; however, this study was published in German and consequently excluded from the current review). Furthermore, Kessing, Agerbo, and Mortensen (2003) found that persons who experienced divorce within the previous year were at high risk of psychiatric hospital admission due to depression. It has been reported that the transition period during partnership dissolutions may trigger the highest level of distress as a result of individuals facing various changes in life circumstances (Blekesaune, 2008). Moreover, under specific circumstances, people may be able to file for a divorce without going through a legal separation period. Therefore, in the context of marital/de facto separation, suicide researchers should identify when the person physically separated from their partner rather than rely on marital status (separated or divorced). Furthermore, research examining specific factors contributing at increasing suicide vulnerability during separation process is extremely limited. It has been widely reported that psychiatric disorders are strongly associated with the development of suicidal behaviors (Conner, Duberstein, Conwell, Seidlitz, & Caine, 2001; Conwell et al., 1996). More than 90% of suicide attempters had at least one current major mental disorder (Rihmer, 2007). Psychological studies showed that divorced persons are strongly represented in psychiatric patient populations (Hassan, 1995; Kreitman, 1988). However, there is only one study identified in the current review that specifically investigated the associations between mental illness and suicide in the context of marital/de facto long-term separation. This study found a significant

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association between depression and divorce among suicide attempters (Dieserud et al., 2003). A number of longitudinal studies have investigated the relationship between marital dissolution and poor mental health using both social selection and social causation theories. These theories argue that mental illness is either a cause of marital dissolution (social selection) or a result of marital dissolution (social causation; Butterworth & Rogers, 2008). Although these studies appear inconclusive, it has been consistently found that psychological distress is highest during the time of partnership dissolution (Blekesaune, 2008; Booth & Amato, 1991; Gahler, 2006; Gardner & Oswald, 2006; Hope, Rodgers, & Power, 1999; Wade & Pevalin, 2004). For example, Booth and Amato (1991) conducted a three-wave panel data study among a national sample in the United States (n = 1,339). This research indicated that the level of distress experienced was linked to divorce itself, with divorced people experiencing much higher distress than married people shortly before their divorce; this difference was not found between the two groups much earlier to the divorce or a few years after the divorce. Hope et al. (1999) conducted a birth cohort study among all children born in 1958 in Great Britain. Psychological distress was measured at 23 years of age (n = 12,537) and at 33 years (n = 11,405). In support of social causation theory, they found that both divorced males and females showed a greater increase in distress during their separation. Although a slightly higher level of psychological distress was found among 23-year-olds who subsequently divorced, it was concluded that the results were confounded by those who were experiencing acute separation. Therefore, the results were due more to anticipation than true selection. In support of social selection theory, a higher level of psychological distress was found among 23-year-olds who remained single compared with those who married later on. Research on suicide has found the acutely separated people, particularly males, seem to be at a higher risk of suicide. However, no studies have been conducted which examine whether people who engage in suicidal behaviors during their separation have already being exposed to other suicide risk factors, such as mental illness, or whether the separation itself leads to increased risk of suicidality (Jacob et al., 2003). Males and females appeared to have different experiences of psychological distress due to separation. A number of studies found that the level of psychological distress reported during marital/de facto dissolution was higher among females than males (Blekesaune, 2008; Gahler, 2006; Hope et al., 1999; Willitts, Benzeval, & Stansfeld, 2005). Furthermore, females reported a lower level of psychological well-being 2 to 4 years prior to the separation, whereas

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males reported their distress much closer to the separation (Blekesaune, 2008; Gahler, 2006). This may explain why females more often initiate marital/de facto separation (Amato & Previti, 2003; Hewitt, Western, & Baxter, 2006). Moreover, a study among males who had separated/divorced within the past year reported that initiators were less distressed and had better health than noninitiators (Kiecolt-Glaser et al., 1988). Therefore, who initiated the separation is an important factor to consider when predicting psychological distress among separated/divorced people. Although females report higher psychological distress than males during the marital/de facto dissolution, separated and divorced men appear particularly vulnerable to suicidal behaviors (Blekesaune, 2008; Gahler, 2006; Hope et al., 1999; Willitts et al., 2005). Males avoid demonstrations of emotion or vulnerability that could be construed as weakness to inhibit emotional expressiveness (Courtenay, 2000; Davis, Matthews, & Twamley, 1999): they often choose aggression and risk taking as responses to stressful events (Grossman & Wood, 1993; Moller-Leimkuhler, 2002a, 2002b), they avoid coping strategies (Halstead, Johnson, & Cunningham, 1993), and they avoid help seeking (Barker & Adelman, 1994; Murphy, 1998; Oliver, Reed, Katz, & Haugh, 1999). All these factors have been linked to suicidal behaviors (Jacob et al., 2003; Murphy, 1998), but they have not yet received proper attention in the context of marital/cohabitant separation. Marital/de facto separation can result in the reduction of normalcy, trigger emotional loss, and breakdown social networks (Denning, Conwell, King, & Cox, 2000). Furthermore, separation could lead to a number of other life changing events such as moving residence, financial change, legal processes, and child custody issues (Maccoby & Mnookin, 1992; Kposowa, 2000; Qin, Agerbo, & Mortensen, 2003; Sweeper & Halford, 2006; I. M. Wasserman, 1984). Attempting to adjust to these multiple layers of life changing events could be beyond individuals coping resources and may lead to the development of psychological strain (Sweeper & Halford, 2006). Furthermore, other psychological factors such as shame (Lester, 1998), self-blame, social introversion (Yen & Siegler, 2003), low-efficacy (Dieserud et al., 2003), hopelessness (Beck, 1986), and problem-solving deficits (Linehan, Camper, Chiles, & Strosahl, 1987) have all been associated with the development of suicidal behaviors. However, there has been no examination of the associations between these variables and the development of suicidal behaviors in the context of marital/de facto separation. In most Western countries, rates of divorce and de facto separation have shown a steady increase over the past few decades (Carmichael et al., 1997). It is possible that these trends result in a continuing increase of suicide rates.

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A greater understanding of how the process of separation may affect the development of suicidal behaviors could be extremely important in reducing suicide rates. This understanding should include a clear gender-specific identification and quantification of: (a) the initiator and noninitiator of the separation and how this affects which phase of the separation process is particularly critical for the development of suicidal behaviors; (b) the psychological factors associated with the process of marital/de facto separation (i.e., depression, low self-esteem, feelings of shame); (c) individual factors (i.e., mental illness, social circumstances, presence of children, coping styles); (d) circumstantial or contextual factors (i.e., living arrangements, economic changes experienced, presence or absence of legal processes); and (e) social and societal factors and pressures, as well as individual perception of being separated and divorced (i.e., attitudes toward divorcees, traditional notions of masculinity). This new knowledge could greatly improve the effectiveness of public health and community-based interventions.

Conclusions
Empirical evidence suggests that marital/de facto separation contributes to higher rates of suicide, particularly in males. The development of suicidal behaviors occurring within the context of separation results from a dynamic interaction between the process of separation, and individual and social factors. Research in this area is now of the utmost importance and cannot be further delayed. It could generate practical recommendations to facilitate comprehensive assessments and treatments among separated people. In turn, theses could be carried out by a range of support services, including government and nongovernment agencies. Awareness of these recommendations would greatly benefit health care professionals. Note
The authors work at the Australian Institute for Suicide Research and Prevention, World Health Organization Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Mt Gravatt Campus, Queensland, Australia.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding
This study was supported by the Australian Research Council, grant no. DP0558922.

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