Journal of Affective Disorders 116 (2009) 208213

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Journal of Affective Disorders

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Research report

Separation as a suicide risk factor

Marianne Wyder a, Patrick Ward b, Diego De Leo a,
a Australian Institute for Suicide Research and Prevention, WHO Collaborating Centre for Research and Training in Suicide Prevention, Grifth University, Mt. Gravatt Campus, Queensland 4111, Australia b School of Integrative Biology, University of Queensland, St Lucia, Queensland 4067, Australia

a r t i c l e

i n f o

a b s t r a c t
Background: Marital separation (as distinct from divorce) is rarely researched in the suicidological literature. Studies usually report on the statuses of separated and divorced as a combined category, possibly because demographic registries are not able to identify separation reliably. However, in most countries divorce only happens once the process of separation has settled which, in most cases, occurs a long time after the initial break-up. Aim: It has been hypothesised that separation might carry a far greater risk of suicide than divorce. The present study investigates the impact of separation on suicide risk by taking into account the effects of age and gender. Methods: The incidence of suicide associated with marital status, age and gender was determined by comparing the Queensland Suicide Register (a large dataset of all suicides in Queensland from 1994 to 2004) with the QLD population through two different census datasets: the Registered Marital Status and the Social Marital Status. These two registries permit the isolation of the variable separated with great reliability. Results: During the examined period, 6062 persons died by suicide in QLD (an average of 551 cases per year), with males outnumbering females by four to one. For both males and females separation created a risk of suicide at least 4 times higher than any other marital status. The risk was particularly high for males aged 15 to 24 (RR 91.62). Conclusions: This study highlights a great variation in the incidence of suicide by marital status, age and gender, which suggests that these variables should not be studied in isolation. Furthermore, particularly in younger males, separation appears to be strongly associated with the risk of suicide. 2008 Elsevier B.V. All rights reserved.

Article history: Received 8 July 2008 Recieved in revised form 11 November 2008 Accepted 12 November 2008 Available online 6 January 2009 Keywords: Suicide Marital status Separation Divorce Risk of suicide

1. Introduction Even though there has been some suggestions that marital separation may be associated with an increased risk of suicide (Cantor and Slator, 1995; Hillman et al., 2000; Kposowa, 2000), separated people (i.e. still married but not living together anymore) have been largely ignored in suicide research. In fact, in most investigations, those who were separated were classied either as married or single indivi-

Corresponding author. Tel.: +61 7 3735 3377; fax: +61 7 3735 3450. E-mail address: d.deleo@grifth.edu.au (D. De Leo). 0165-0327/$ see front matter 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2008.11.007

duals or grouped together with divorced subjects. This is of concern as marital breakdown is associated with increased risk of psychological distress (Maughan and Taylor, 2001). The few studies that have included separation as a distinct category suggested that the risk could be especially high for separated males (Cantor and Slator, 1995; Kposowa, 2000). Theoretically, the effect of marriage and relationship breakdown is expected to differ by gender and age (Mastekaasa, 2006). Status integration theory suggests that infrequent or uncommon combinations of social statuses and roles make social relationships unstable (Gibbs, 2000). Little is known about the way age, gender and marital status affect suicide rates (Kposowa, 2000).

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Furthermore, there is currently considerable debate whether the relationship between marital separation and adverse outcome on health reect causal inuences (the distress associated with marital separation) or selection effects (psychologically healthy people are more likely to marry and to remain married) (Cheung, 1998; Goldman, 1993; Hemstrong, 1996; Hope et al., 1999; Joung, 1997; Smith et al., 1988). Similarly, some have suggested that the association between separation and/or divorce and suicide would be better explained by the effect of a psychiatric illness (Cheung et al., 2006; Kessler et al., 1999), with the latter either interfering with separation, suicide or both. The present study aimed to investigate the prevalence of suicide among separated people by taking into account the effect of age and gender. Psychiatric illness was also controlled for. 2. Methods This study adopted the following categories of marital status: married or in a de facto relationship, separated, divorced, single/never married, and widowed. Marriage is dened as two people living together as husband and wife as per the Australian Marriage Act (1961). A de facto marriage is dened as the relationships between a man and a woman who are not legally married but live together as husband and wife. In Australia, separation is dened as the period between the marital break-up and the divorce, and occurs as soon as one spouse permanently leaves the conjugal home (Family Law Act 1975; Marriage Act 1961). Divorce is granted only after a couple has been separated on a continuing basis for at least 12 months. While separation from a de facto relationship carries similar obligations as separation from a formal marriage it does not require a formal divorce. In the current investigation, separations from these two types of marriages are treated as equivalent. 2.1. Data sources Records of suicide were obtained from the Queensland Suicide Register (QRS), a database maintained by the Australian Institute for Suicide Research and Prevention (AISRAP), which records all cases of suicide in Queensland (QLD). Information in this database comes from coroners and police reports, as well as from psychological autopsy forms designed by AISRAP and completed by police ofcers with proxies of the deceased. The psychological autopsy interview includes demographics, life events, psychiatric history of the deceased and other information deemed relevant by the investigating ofcer (see De Leo and Klieve, 2007; De Leo et al., 2006 for a more detailed description). The period analysed for this study spanned from 1994 to 2004. During this period, the marital status of suicide victims was not reported in 19% of the cases. It should be noticed that in this databank, operating uninterruptedly since 1990, the collection of psychiatric data relied on information collected during coroner's investigation and through interviews (Form 1) by police with proxies of the deceased and eventually GPs. Currently, in the QSR the incidence of psychiatric illness is of 39.6% (QSR latest reading: 22.5.2008), a percentage remarkably lower than those usually

reported in the literature (for example: Lnnqvist, 2000). The low incidence of psychiatric illness in the QSR can be explained by the fact that the data collection relies on police and coronial information only. The incidence of psychiatric illness is commonly lower when purely based upon coroner's information (Snowdon et al., submitted for publication). In fact, different types of quality-control studies performed on the QSR database have brought to different results in terms of frequency of psychiatric diagnoses (De Leo and Krysinska, 2008). In one of these studies, a trained psychologist performed the same interview (Form 1) with proxies of the deceased at six-month distance from the event. The percentage of detectable psychiatric conditions increased to 55% (representative sample of 100 cases). When the SCID (Spitzer et al., 1996) was added to the interview, the percentage increased to 67.5% (consecutive sample of 260 cases; De Leo et al., in preparation). The latter study did not included suicides aged 35 and under. It is also important to note that, while minor mental disorders may not be included within the dataset, the prevalence of major depression, bipolar disorder and psychotic disorders in the QSR appears to be congruent with studies involving mental health interviewers or structured diagnostic instruments (De Leo and Klieve, 2007). The 1996 and 2001 Queensland population censuses (latest available at the time of manuscript preparation) were used as a proxy for the state population (Australian Bureau of Statistics, 2001a,b). The census information includes two separate classications for marital status, namely the Registered Marital Status and the Social Marital Status. The Registered Marital Status refers to legal status categories such as married, never married, widowed, divorced and separated. Consequently, those who live in a de facto relationship are mostly classied as never married (and, less frequently, as widowed or divorced). On the other hand, the Social Marital Status considers current living arrangements and categorises in married in a registered marriage, married in a de facto marriage and not married. By combining these two classications, the number of people recently separated (from marriage or de facto relationships) could be counted. Due to misclassications associated with the marital status categories across the two registries, a certain number of persons fell into more than one category. In fact, in the 1996 census 12,091 persons (.5% of the total sample) were classied twice. No person was classied twice in the year 2001. 3. Statistical analysis The contributions of age, gender and marital status to suicide risk were assessed using likelihood ratio tests. Maximum likelihood in a linear regression modelling of suicide risk was performed by considering each subject as a binomial trial in the sense of being in the QSR or not. Regression models for the effects of age, gender and marital status on the probability of being in the suicide register were tted using the glm module of the R statistical package (R Development Core Team, 2006). Errors were assumed to follow a binomial distribution, and the log link function was used (rather than the logit default) in order to directly estimate relative risk. Subjects with incomplete information were excluded from the analysis. Suicide risks

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M. Wyder et al. / Journal of Affective Disorders 116 (2009) 208213 Table 3 Relative risks (RR) and condence intervals (CI) for suicide by gender, marital status and age. Age 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+ Status Married Married Married Married Divorced Divorced Divorced Divorced Separated Separated Separated Separated Single Single Single Single Widowed Widowed Widowed Widowed RR and CI for males (95%) 7.57 (5.3210.79) 3.97 (2.935.37) 3.35 (2.464.54) 4.12 (35.66) 20.69 a 7.97 (5.6911.16) 6.85 (4.939.51) 6.31 (4.119.68) 91.62 (59.65140.7) 33.53 (24.6345.64) 17.6 (12.724.39) 11.61 (7.3218.4) 4.55 (3.366.17) 7.83 (5.7910.60) 4.04 (2.835.67) 2.38 (1.583.6) 10.73 (4.5823.74) 6.25 (3.7310.49) 8.16 (5.7711.55) RR and CI for females (95%) 1.39 (.882.19) 1.16 (.841.60) .89 (.631.26) 1 (Reference category) 2.46 (1.673.62) 1.91 (1.292.85) 1.22 (.582.59) 4.27 (1.5411.85) 3.65 (2.485.38) 3.63 (2.345.63) 1.58 (.495.08) 1.13 (.801.59) 2.29 (1.623.24) 1.17 (.701.97) .25 (.09.71) 2.41 (.966.06) 1.45 (.842.51) .85 (.561.29)

Table 1 Chi-Square test for main effects, two- and three-way interactions between age, gender and marital status (QSR compared to QLD Census population). Factor Age Gender Age and gender Marital status Age and marital status Gender and status Age, gender and status df 3 1 3 4 12 4 12 Chi-square 145.4 1972.9 8.6 1276.2 207.6 64.1 20.034 P-value b.0001 b.0001 b.05 b.0001 b.0001 b.0001 ns

are expressed relative to risk of suicide by married females over the age of 65. The estimates of relative risk were based on the average of the 1996 and 2001 census counts. Even though the Queensland population did not remain static during this period, the relative risk of suicide followed similar patterns across categories of marital status, age and gender regardless of whether the 1996 or the 2001 data were used. Logistic regression was also used to assess the distribution of unknown marital status across categories of age and gender. Logistic regression was also performed to assess the effects of age, gender and marital status on the occurrence of psychiatric illness as reported within subjects in the QSR. A similar logistic regression was performed on one of the Quality Control Studies (representative sample of 100 cases). 4. Results Between 1994 and 2004, 6062 persons died by suicide in QLD (an average of 551 per year) and males outnumbered females by four to one (see Table 1 for detail). The main effects

a The condence intervals for young divorced males have not been included as the numbers in this category were too small and the estimate of the variance was considered to be unreliable.

Table 2 Distribution of marital status of males and females in QSR and QLD. Age Marital status Males in Males in QLD Females Females in QLD QSR in QSR (n) (n) Average Average 19962001 a (n) 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+ 15 to 24 25 to 44 45 to 64 65+
a

19962001 a (n) 31 217 122 45 0 59 53 8 4 59 36 3 120 113 21 4 0 5 18 43 41,688 349,043 255,355 84,084 659 44,852 51,713 12,256 1749 30,144 18,487 3546 198,680 92,011 33,464 29,372 278 3881 23,150 94,374

Married Married Married Married Divorced Divorced Divorced Divorced Separated Separated Separated Separated Single Single Single Single Widowed Widowed Widowed Widowed

96 653 486 250 4 137 170 39 37 386 179 30 548 593 94 45 0 7 21 109

23,606 307,037 271,109 113,050 356 31,991 46,215 11,514 718 21,136 18,834 4802 224,511 140,920 43,448 35,300 132 1213 6258 24,852

and two-way interactions between age, gender and marital status were all signicant (Table 2). The three-way interaction was not signicant, indicating that the trends seen across age and marital status may be considered parallel between males and females. Overall, males had a higher suicide risk (RR = 4.12) than females. While the trends observed across all categories of age and marital status for males broadly mirrored those of females it is important to note that the condence intervals for divorced and separated females were overlapping suggesting that there were no signicant differences between these two categories. For females, while there were no signicant differences between the marital status of separated, there was some suggestion that both decreased with age. In contrast, among single women suicide risk was elevated only for those aged 2544 years (RR = 2.29). Being single and over 65 years of age appeared to be a protective factor (RR = .25) (Table 2). Younger separated males were at the highest risk (RR = 91.62); this risk progressively decreased with age (RR = 11.6 for those over 65). Compared to the other marital statuses, divorced men also had a substantial higher risk of suicide, which also decreased with age. However, for divorcees the risk was overall less than half of separated men. The risk for
Table 4 Chi-Square test for two- and three-way interactions of psychiatric illness on age, gender, marital status (based on QSR dataset). df Age Gender Marital status Age and marital status Age and gender Gender and status Age, gender and status 3 1 4 11 3 4 10 2 47.3 112.5 10 21.3 2.4 2.3 16 P b .0001 b .0001 b .05 b .05 ns ns ns

The ABS census data does not include QSR data.

M. Wyder et al. / Journal of Affective Disorders 116 (2009) 208213 Table 5 Chi-square values from log-linear model for main and two-way interaction effect of psychiatric illness on age, gender and marital status. P-value 1524 2544 45 to 64 65+ Male Female Divorced Never married Separated Widowed Married 15 to 24 Divorced 25 to 44 Divorced 45 to 64 Divorced 15 to 24 Never married 25 to 44 Never married 45 to 64 Never married 15 to 24 Separated 25 to 44 Separated 45 to 64 Separated 15 to 24 Widowed 25 to 44 Widowed 45 to 64 Widowed The asterisk stands for Reference Category. b .0001 ns ns Reference category b .0001 RC ns ns ns ns RC ns ns ns b .0001 b .003 b .02 ns ns ns b .04 ns

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single men was also high among those aged 25 to 44 (RR = 7.83) and low for those over 65 (RR = 2.38) (Table 2). Those of unknown marital status (19% of suicides) were analysed separately. Their characteristics did not signicantly differ from the total sample in terms of age, gender and presence of psychiatric conditions. In the QSR data, a psychiatric condition was mostly present among males who had never married and were between the ages of 15 and 44. However, no association with either separation or divorce and psychiatric illness was found (Tables 3, 4, and 5). The analysis of the Quality Control Study yielded similar results. The psychiatric illness was mainly present among those who had never married (regardless of age or gender) (chi-square 12.6, df = 5 and P b.05). 5. Discussion This study highlighted that the prevalence of separated males and females was much higher than any other marital status, even when compared to those who were divorced. Furthermore, the results indicate that the effects of age, marital status and gender should not be studied in isolation, since a more intricate picture emerges when a full crossclassication is considered. For example, while separation or divorce represented a higher risk for all age groups, the risk was particularly high in the younger age groups. Marriage had the lowest relative risk for those aged 65 and over, but did not appear to benet those aged 15 and 24. Conversely, the relative risks for single people in the younger age groups were lower but peaked in the 25 to 44 year old age group. Durkheim (1897/1951) suggested that marriage provided protection against suicidal behaviours, as people would be more integrated in a supportive social network. When these bonds are broken by separation and divorce, the risk for suicide would increase (Durkheim, 1897/1951). This theory

still receives support today (Giddens, 2001; Hassan, 1996, 1998; Jacob et al., 2003; Stack, 2000). Gibbs and Martin (1964) hypothesised that those marital statuses that occur infrequently in society lead to higher role conict, which in turn increases the risk of suicidal behaviours. For example, in countries where divorce is rare, the suicide rates for divorced people are higher (Gibbs and Martin, 1964; Gibbs, 2000). In most western societies being married and divorced under the age of 25 is rare (Australian Bureau of Statistics, 2001a,b) and people within this age group and marital categories are more likely to experience higher levels of stress. For example, the nancial and emotional stressors in young married couples may be greater than in older ones (Yip and Thornburn, 2004). Conversely, the stress of being single between the age of 25 and 44, a period where most people marry and start a family, may increase the risk of suicide because people may feel that they have failed to achieve their own goals. Similarly, it has been suggested that variables like antisocial behaviour, alcohol or substance abuse and conduct disorders are positively related to early partnership formation (Forthofer et al., 1996; Fu and Goldman, 1996; Maughan and Taylor, 2001) and that children from disrupted homes are more likely to marry and have children at an early age (McLanahan and Bumpass, 1988; Kiernan and Cherlin, 1999). Similar ideas were found in the life course literature where there is a distinction between on-time and off time events. This literature suggests that those experiencing off-time events (in this case separating at a young age) would have less coping skills to deal with the psychological distress experienced (Mastekaasa, 2006). It is possible that pre-existing issues such as psychiatric illness, anti-social behaviour or poor coping skills may have contributed to the relationship breakdown and suicide. Conversely the relationship breakdown may have caused intense feelings of distress which inuenced the suicide. From the current study it is difcult to make denite conclusions about the impact of separation or pre-existing vulnerabilities as other risk factors such as education, income and presence or absence of children were not controlled for. These variables may inuence both marital status and suicide. Equally, it is possible that the relationship breakdown actually caused the distress as for many people the loss of a relationship is an inherently stressful life event, which could produce feelings of low self esteem and loneliness. These feelings may lead to depression, hopelessness and suicidal ideation, which in turn may trigger/facilitate suicide (Dieserud et al., 2001; Kposowa, 2000). In the current study there was some suggestion that the association between separation and suicide risk was largely independent from the presence of a psychiatric illness. This nding parallels that of Duberstein et al. (2004), who showed that the association between family and social/community indicators of poor social integration and suicide is largely independent from psychiatric disorders. Whether or not it is the pre-existing condition or the separation that is causing the distress it is important to consider that separation and divorce both constitute a high risk for suicide, with separation (especially in males aged 1524) appearing to be a particularly challenging condition. Marital breakdown is associated with an increased risk of psychological distress (Maughan and Taylor, 2001) and that the impact of this stress is the highest in the rst year of the separation. General studies into separation have suggested that men and women

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who had experienced a relationship breakdown and were alone at the time of the interview experienced the highest levels of mental health difculties (Mastekaasa, 2006). The period of separation is a particular stressful time for many people and, for some could signicantly contribute to the development of suicidal behaviours. The elevated risk of suicide for divorced females reported by Cantor and Slator (1995) in QLD between 1990 and 1993 disappeared between 1994 and 2004. This change may mirror a trend in western countries for the ratio of divorced to married suicides to narrow (Charlton, 1995; Hassan, 1995; Heikkinen et al., 1995; Kposowa, 2003; Lorant et al., 2005; Smith et al., 1988; Stack, 1990; Trovato, 1986; Yip and Thornburn, 2004). Furthermore, while the trends observed across all categories of age and marital status broadly mirrored those of females, suicide risk for males was much higher. This higher risk may reect the way males socialise, as they more often rely solely on their partners for emotional and social support, whereas females often have a wide network of family and friends who provide this support. Consequently, the greater protection from suicide in women may be attributed to their higher degree of attachment to signicant others (Cantor and Slator, 1995; Trovato, 1991). Traditional notions of masculinity may partly explain men's vulnerability to suicide, as males are more likely to avoid demonstrations of emotion or vulnerability that could be construed as weakness (Courtenay, 2000; Davis et al., 1999); to inhibit emotional expressiveness and choose aggression and risk-taking as responses to stressful events (Grossman and Wood, 1993; Moller-Leimkuhler, 2002a,b); to use avoidant coping strategies (Halstead et al., 1993); and to limit help-seeking behaviour (Barker and Adelman, 1994; Murphy, 1998; Oliver et al., 1999). All these attitudes have been independently linked to suicidal behaviours (Jacob et al., 2003; Murphy, 1998). In the current study, those who were single and over 65 presented the lowest relative risk of suicide, both in men and women. This nding appears to contradict previous evidence that marriage is the most consistently protective factor against suicide (Ben Park and Lester, 2006; Gunnell et al., 2003; Leenaars and Lester, 1995; Lester, 1994; Lorant et al., 2005; Yip and Thornburn, 2004). However, one previous study has reported similar results, with older suicides being signicantly more likely to be married or widowed (Carney et al., 1994). It is possible that over the years, older single people have developed strong social networks and coping strategies and are therefore better equipped to deal with life's stressors on their own. 6. Limitations

signicantly inuenced the results. Lastly, this study only investigated the impact of marital separation on suicide risk but did not control for other variables such as education, income, the presence or absence of children which previous studies have shown can also signicantly impact upon separation/divorce as well as suicide risk. The study did control for psychiatric illness, however information regarding psychiatric illness at the time of the suicide is based on police interviews with proxies at the time of the death. As was noted, for a variety of reasons, the incidence of psychiatric illness may be underreported in the QSR, especially when illicit drug use and minor psychiatric conditions (e.g., anxiety disorders and personality disorders) were involved. However the fact that the prevalence of major depression, bipolar disorder and psychotic disorders is similar to those reported elsewhere in the literature (De Leo and Klieve, 2007) and, that the logistic regressions performed on the QSR and Quality Control Study yielded similar results, appears to corroborate the nding that suicide risk in separation is independent from the presence of a psychiatric illness. 7. Conclusions The data from this study strongly suggests that separation, in particular for younger males, is an important risk factor for suicide. However, we cannot be certain that this is due to the separation itself or some characteristics of these males that are both related to the early life transitions (like marriage and separation) and suicide. Considering the current raise in divorce rates (Australian Bureau of Statistics, 2001a,b; Carmichael et al., 1997), the increasing number of de facto marriages, and the large proportion of suicides that are associated to relationship breakdowns, a better understanding of how the transition from marriage to separation and/or divorce may inuence the development of suicidal behaviours could have a powerful inuence on reducing suicide rates.
Role of funding source Nothing declared. Conict of Interest No conict declared.

Acknowledgement Queensland Health provides continuing support to the Queensland Suicide Register. References

A number of limitations should be noted. Firstly, the information regarding marital status was missing for 19% of the suicides. While there was no suggestion that any particular age and/or marital status category had been subject to different degrees of underreporting, it is possible that this may have affected the results. Secondly, the category of married/de facto for the QLD population was based on a combination of two different marital classication systems. While more than 99.7% of the population was only classied once in the merging of the two systems, it is possible that further misclassications were introduced within different marital statuses. However, it is unlikely that these may have

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