Learning From Lives That Have Been Lived

7/28/2019 Learning From Lives That Have Been Lived

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LearningFromLivesThatHaveBeenLived


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NUNAVUTSUICIDEFOLLOW-BACKSTUDY2005-2010


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FundedandSupportedby:

NunavutTunngavikInc.

EmbraceLifeCouncil

GovernmentofNunavut

CanadianInstitutesfor

HealthResearch

McGillUniversity

DouglasMentalHealthUniversityInstitute

RoyalCanadianMounted

Police

NunavutCoronersOffice


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NunavutSuicideFollow-BackStudy:IdentifyingtheRiskfactorsforInuit

SuicideinNunavut

WiththeNunavutSuicideFollow-BackStudySteeringCommitteeandtheMcGillGroup

forSuicideStudies

PreparedbyDr.EduardoChachamovichandMonicaTomlinson,incollaborationwith

EmbraceLifeCouncil,NunavutTunngavikInc.,andtheGovernmentofNunavut.

DouglasMentalHealthUniversityInstitute

6875LaSalleBoulevard,FBC-3

Montreal,Quebec

Canada,H4H1R3Phone:(514)761-6131#3301

Fax:(514)762-3023


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Acknowledgements

WewouldliketothankallNunavummiutwhokindlysupportedthisstudy.In

particular,wewouldliketoexpressourmostsinceregratitudetotheNunavummiutwho

gaveustheirtimeandknowledgebyacceptingtobeinterviewedandbyanswering

questionsthattouchedextremelysensitivetopics.Ittookgreatcourage.

SuchgenerouscontributionsaddedtoabetterunderstandingofsuicideinNunavut

andwillbeimportantindevelopingmoreefficientstrategiestohelpcommunitiesaddress

furtherlossesbysuicideinthefuture.

Wewouldliketoalsothankthecommunityhealthcenters,hamlets,and

communityhousingcorporationstafffortheirvaluablesupportandhelp.Thanksare

equallyextendedtotheinterpreterswhomadeitpossibleforallcontributorstotakepart

equallyinourstudy.Allinterviewers,researchersandadministrativestaffwhohelpedus

intheprocessofpreparingthisprojectwereinvaluableanddeserveduegratitude.

Last,butcertaintynotleast,wewouldliketothanktheNunavutFollow-BackStudy

SteeringCommitteefortheirguidanceandinputduringthestudy.Thesepartnersarealso

membersoftheNunavutSuicidePreventionStrategy.


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TableofContents

FundedandSupportedBy......3

Acknowledgements.......5

ExecutiveSummary.....8

ABriefHistoryofSuicide11

SuicideGlobally.....11

SuicideinAboriginalPopulations11

SuicideandMentalHealth...15

IntheGeneralCanadianPopulation..15

AmongInuitinNunavut....15

DescriptionoftheStudy.......17

Background.17

TheNunavutFollow-BackStudy:WhatIsIt......17

Funding........17

Approval....18

Confidentiality..18

TheNunavutFollow-BackStudy:HowDidWeDoIt?............................................................18

DiagnosingMentalIllness....21

AdditionalMeasures...22

Table1:NunavutFollow-BackStudyDesign...23

Figure1:ADetailedOverviewoftheNunavutFollow-BackStudyDesign.25

DemographicCharacteristics....26

Sex.26

AgeofDeathforSuicideGroup...26

Occupation.27

MaritalStatus...27

LevelofEducation.28

JudicialProblems..28


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NumberofPeopleLivinginEachHousehold ...29

Adoption..29

BiologicalandAdoptedSiblings..30

BiologicalandAdoptedChildren.31

ChildhoodMaltreatment.....32

AggressionandImpulsiveness..34

MentalHealth.....35

Table2:CategoriesofMentalIllness....36

MajorPsychiatricIllness.........37

MajorDepressiveDisorder(MajorDepression)......39

CannabisAbuseorDependence..41

AlcoholAbuseorDependence....42

PersonalityDisorders..43

BorderlinePersonalityDisorder..44

ConductDisorder ....45

AntisocialPersonalityDisorder ...45

PsychiatricCare......47

PsychiatricMedication...47

PsychiatricHospitalization.48

NumberofHospitalizations..49

Limitations.....50

Conclusion......51

References...53


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ExecutiveSummary

Suicideisaglobalissue.Countriesaroundtheworldareaffectedbysuicide,and

manyareimplementingnationalsuicidepreventionstrategiestocurbthisissue.The

WorldHealthOrganization(WHO)estimatesthattherearealmost1milliondeathsby

suicideintheworld,peryear.

NowhereisthisproblemasstrikingandextremeasincertainAboriginal

populations.InNunavut,therateofdeathbysuicideamongInuithasincreasedmarkedly

overthelastthreedecades,anditiscurrentlyjustover120per100,000people,10times

theCanadiansuiciderate.

ThemaingoalofQaujivallianiqInuusirijauvalauqtunikLearningfromlivesthat

havebeenlivedwastoidentifythereasonsbehindeachdeathbysuicideinorderto

bettercomprehend,predict,andeventuallypreventsuicideinthefuture.Afollow-back

designwasused,whichlooksretrospectivelyintothelivesofbothindividualswhodiedby

suicideandindividualswithcomparablebackgroundswhoarestilllivingtoidentifyrisk

andprotectivefactorsassociatedwiththesuicide.

Theprojectincluded498interviewswiththefamilyandfriendsofall120suicides

thatoccurredinNunavutbetweenJanuary1,2003andDecember31,2006aswellas120

livingindividualswhohadclosedatesofbirth,camefromthesamecommunityoforigin,

andwerethesamegenderasindividualsinthesuicidegroup(thewasourcomparison

group).

InNunavutbetween2003and2006,moremalesthanfemalescommittedsuicide.

Themaximumageinthestudywas62yearsoldandtheminimumagewas13.The

averageageofindividualswhodiedbysuicidewas24.6yearsold.

DemographicDifferencesBetweentheSuicideandComparisonGroups

Moreindividualsinthecomparisongroupweremarriedorinacommon-lawrelationship,whereasmoreindividualsinthesuicidegroupweresingle;

Moreindividualsinthecomparisongroupwereemployedorinschoolandmoreindividualswhodiedbysuicidewereunemployed;


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Individualsinthesuicidegroupweremorethantwiceaslikelytohavebeeninvolvedinlegalproblemscomparedtothelivingindividuals;

Individualswhodiedbysuicidewerealmostfourtimesaslikelytohavehadlessthan7yearsofeducationthanthecomparisongroup.

DifferencesinChildhoodExperiencesBetweentheSuicideandComparisonGroups

Significantlymoreindividualsinthesuicidegrouphadexperiencedchildhoodabusethanthecomparisongroup;

Significantlymoreindividualsinthesuicidegrouphadbeenphysicallyand/orsexuallyabusedinchildhoodthanthecomparisongroup.

DifferencesinImpulsivenessandAggressionBetweentheSuicideandComparison

Groups

Levelsofbothimpulsivenessandaggressionweresignificantlyhigheramongthosewhodiedbysuicide.

DifferencesinDiagnosesofPsychiatricIllnessBetweentheSuicideandComparison

Groups

Significantlymoreindividualsinthesuicidegroupwerediagnosedwithcurrent(past6months)orlifetimemajordepressivedisorderthanthecomparisongroup;

Significantlymoreindividualsinthesuicidegroupwerediagnosedacurrentorlifetimecannabisdependenceorabusedisorderthanthecomparisongroup;

Twiceasmanyindividualsinthesuicidegroupwerediagnosedacurrentalcoholabuseordependencedisorderthanthecomparisongroup.Therewereno

differencesinlifetimealcoholabuseordependence.Thisindicatesthatalcohol

abuseordependencemaybeamoreacuteriskfactorforsuicide.

DifferencesinPersonalityDisordersBetweentheSuicideandComparisonGroups

Significantlymoreindividualsinthesuicidegroupwerediagnosedwithborderlinepersonalitydisorder,conductdisorder,andantisocialpersonalitydisorderthan

thecomparisongroup.

ParticipantsUseofMentalHealthCareWheninNeed


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Twiceasmanyindividualswhodiedbysuicidetookpsychiatricmedicationthanthecomparisongroup.However,themajorityofindividualsdidnottake

psychiatricmedication(80%);

Twiceasmanyindividualswhodiedbysuicidewerehospitalizedforapsychiatricillnessthanthecomparisongroup;

Significantlymoreindividualswhodiedbysuicidewerehospitalizedmorethanonceforapsychiatricillnesscomparedtothecomparisongroup

Theseconcretefindingsarepivotalinunderstandingwhereresourcesshouldbe

focusedtopreventsuicideinthefuture.Theeffectiveandsensitiveuseoftheseresults

canassistusinachievingthevisionofthePartnersoftheNunavutSuicidePrevention

StrategyaNunavutinwhichsuicideisde-normalized,andwheretherateofsuicideisthesameastherateforCanadaasawhole,orlower.


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ABriefOverviewofSuicideResearch

SuicideGlobally

Suicideisaglobalissue.Countriesaroundtheworldareaffectedbysuicide,and

manyareimplementingnationalsuicidepreventionstrategies24.TheWorldHealth

Organization(WHO)reportsthatdeathsbysuicideaccountforalmost1milliondeathsin

theworld,peryear.Globalestimatedratesofdeathbysuicideare14-15deathsper

100,000individuals,whichmeansthatonedeathbysuicideoccursaboutevery40

seconds24.

InCanada,asinmostofthedevelopedworld,suicideisamongthetoptenleadingcausesofdeath.Whilesuicideratesamongelderlyhavedecreasedinmostcountries,

suicideratesforyoungerindividualshaverisen.Formalesyoungerthan40yearsold,

suicideistheleadingcauseofdeathworldwide24.

Globally,suicideisassociatedwithseveralunderlyingfactors,withmentalhealth

beingthemostpervasive.Suicideratesvaryfromcountrytocountrydependingon

ethnicity,occupation,employmentstatus,region,andgender24.

Consistently,suicideclaimsthelivesofmorementhanwomen.Otherfactorsthatarewellknowntoincreaseanindividualsvulnerabilitytodyingbysuicideincludehistory

ofchildhoodmaltreatment,exposuretosuicidalbehaviourinhisorherfamily24,and

previoussuicidalbehaviour51.

SuicideinAboriginalPopulations

NowhereisthisproblemasstrikingandextremeasincertainAboriginal

populations.Worldwide,certainindigenouspopulationshavehighersuicideratesthan

theircountrysnon-Indigenouspopulation.Forexample,AustralianAborigines,Maoriin

NewZealand,andNativeAmericansintheUSallhavehighsuiciderates24.

WhilesomeAboriginalpopulationshavesuicideratescomparabletoorlowerthan

thegeneralCanadianpopulation(forexample,theCreeinQuebec),studiesinregions


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containingbothAboriginalandnon-AboriginalpopulationsoftenfindtheAboriginal

suicideratestobemuchhigherthanthoseintherestoftheworld.

Inuit,forexample,havehadamongthehighestratesofsuicideinthelastforty

years.In2000theoverallFirstNationssuicideratewas24peopleforevery100,000(two

timesthegeneralCanadiansuiciderate35).AmongInuit,however,thesewerea

staggering135peopleforevery100,000between1999and200314.Suicideratesamong

Inuithavebeen,onaverage,tentimeshigherthanthegeneralCanadianpopulationfor

morethan4decades.TheseratesareincontrastwiththelowratesofsuicidethatInuit

societieshaduntilaboutfourdecadesago48.

InNunavut,therateofdeathbysuicideamongInuitincreasedmarkedlyoverthe

lasttwodecades,anditiscurrentlyjustover120per100,000people.56%percentof

suicidesinNunavutarecommittedbymenyoungerthan25,comparedto7%inCanada.

TheriseinNunavutsrateofdeathbysuicideisalmostentirelytheresultofanincreased

numberofsuicidesbyInuityoungerthan25.TherateofdeathbysuicideamongNunavut

Inuitaged15to24hasincreasedmorethansix-foldsincetheearly1980s27.

Beyondactualdeathsbysuicide,ratesofsuicideattemptsandsuicidalideation

(thoughtsofcommittingsuicide)appeartobeveryhighinNunavut.Recentdatacollected

attheQikiqtaniGeneralHospitalindicatethatinjuriescausedbysuicideattemptsaccountforalmosthalfofalltheinjuriesamongpeopleage2029

57.ResultsfromtheInuitHealth

Surveyshowthat48%ofInuitinNunavuthavethoughtaboutcommittingsuicideatsome

pointintheirlives,whereas29%reportedhavingattemptedsuicideatsomepointintheir

lives21.

ThefrequencyofreportedsuicidalthoughtsamongInuitinNunavutishigherthan

thatreportedamongFirstNationsCanadianswhere,accordingtotheFirstNations

RegionalLongitudinalHealthSurvey,31%ofadultsreporthavinghadsuicidalthoughtsatsomepointintheirlives

5.Thisishigherthantherateof13%fortherestofCanada

36


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ThefollowinggraphshowsthenumberofsuicidesamongInuitinNunavutfrom1961-

2009.

ThefollowingchartpresentsthehighratesofsuicideamongInuitinNunavutcomparedto

therestoftheCanadianpopulationfrom1982to2008.


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ThefollowingcharthighlightsthehigherratesofsuicideamongyoungInuitmales,

comparedtothegeneralCanadianpopulation28

.

Between2003and2006,120InuitdiedbysuicideinNunavut.Thefollowinggraphshows

thenumberofsuicidesperregioninNunavut,withthehighestratesofsuicidebeinginthe

Qikiqtaalukregion(BaffinRegion).

0 10 20 30 40 50 60 70 80 90

QikiqtaalikRegion(BafDinRegion)

Kitikmeot

Kivalliq

NumberofSuicides

NumberofSuicidesperRegioninNunavut

Between2003and2006


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SuicideandMentalHealth

IntheGeneralCanadianPopulation

Studiesaroundtheworldhaveconsistentlydemonstratedthatdeathbysuicideis

frequentlyassociatedwithmentalhealthissuessuchasdepression,anxietydisorders,

personalitydisorders,anddrugandalcoholabuseanddependencedisorders24.Often

individualswhohaveonementalillnessmayalsomeetthecriteriaforoneormore

additionalmentalillnesses24.Infact,mentalhealthissuesareconsideredoneofthemost

importantriskfactorsforsuicide.Inotherwords,whensomeoneishavingmentalhealth

problems,thispersonbecomesmorevulnerabletosuicidalideationanddyingbysuicide4.

AmongInuit

Studieshaveshownthatmentalhealthproblemsareimportantfactorsforsuicidal

behavioursinInuitpopulationsaswell.Individualswithsuicidalideationorthosewho

diedbysuicideweremorelikelytohaveanxiety,depressionanddrugandalcoholabuse

ordependenceproblems8,23,33,34

.

In2008theGovernmentofNunavut,NunavutTunngavikInc.,theEmbraceLife

Council,andtheRoyalCanadianMountedPoliceformedapartnershiptocreatea

NunavutSuicidePreventionStrategy.Theyreviewedevidencebasedresearchon

methodsthathavesuccessfullyreducedsuicideinotherjurisdictions,releaseda

discussionpaper,conductedcommunityconsultations,andmetwithallkeystakeholders

involvedwithsuicideprevention.InOctober2010,theStrategywastabledinthe

LegislativeAssemblyofNunavut.

TheStrategyindicatesthatsignificantinvestmentsarerequiredformentalhealth

servicesandevidencebasedinterventions.Inaddition,thePartnersnotedthe

importanceofensuringallaspectsofsuicidepreventionareconsidered-prevention,


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intervention,andpostvention.ThecompaniondocumenttotheStrategy,theNunavut

SuicidePreventionStrategyActionPlan,wasreleasedinSeptember2011.Itoutlinesthe

actionstobetakenundertheeightcommitmentsoftheStrategy.


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DescriptionoftheStudy

Background

Thisreportwascreatedtohonourtheresearchersobligationtopresentformal

feedbacktothestakeholdersaspartoftheCanadianInstitutesforHealthResearch(CIHR)

requirements.

Thisreportisalsopartofalargerstrategytomaketheseresultspublicandavailable

tothosewhoareinterestedinthem.

TheNunavutSuicideFollow-BackStudy:Whatisit?

Afollow-backstudylooksretrospectivelyatthelivesofagroupofindividualswho

diedbysuicideandacomparisongroup(livingindividualswiththesamedemographic

background)toidentifyriskandprotectivefactorsassociatedwiththesuicide.Looking

retrospectivelyatthelivesofbothindividualswhodiedbysuicideandindividualswho

arestilllivingallowsustocollectalargeofamountofdetailedinformationonthelivesof

bothgroupssothatwemaybetterunderstandwhysomeindividualsareatahigherrisk

ofdyingbysuicidethanothers.

Thisisthefirstlarge-scalestudyofitskindtobeconductedwithInuitcommunities

intheworld.Thegoalistoidentifythereasonsbehindeachdeathbysuicideinorderto

bettercomprehend,predict,andpreventsuicideinthefuture50.

Funding

FundingforthisprojectwasreceivedfromtheCanadianInstitutesforHealth

Research(CIHR).TheGovernmentofNunavutalsoprovidedfundingforthefinalstepsof

theproject.

TheFondsderechercheduQubec-Sant(FRQS)andtheCanadianInstitutesfor

HealthResearchalsofundedthedevelopmentoftheknowledgetranslationstrategies.


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Approval

TheDouglasUniversityMentalHealthInstitutesInstitutionalReviewBoard

providedethicalapproval.TheNunavutResearchInstitutealsoissuedtheresearch

license.

Confidentiality

Participantsconfidentialitywashandledwithextremecareinthisstudy.Namesare

keptconfidentialatalltimesandtheresearcherswillnotreleaseinformationonsingle

communities,familiesorindividuals.Resultswillalwaysbepresentedinawaythat

ensurescompleteanonymity.

Duringinterviews,participantswerefreetopauseandinterrupttheresearcher

whenevertheyfeltitappropriateornecessary.Participantswerealsogiventheoptionof

withdrawingfromthestudyatanytime.Allparticipantswerefinanciallycompensatedfor

theirparticipationandwereofferedthechoiceofkeepingthecompensationordonating

ittoanorganizationtheywereinterestedinsupporting.

Whenanyparticipantwasindistressatanypointduringtheinterview,the

researcherswereobligatedtorefertheparticipanttoahealthcareprofessional,orbring

themtothehealthcarecentre.Theresearchteamwasalwaysaccessiblebyphoneor

emailforanyquestionsorconcernsregardingthestudy.

Beforeapproachingeachcommunity,theresearchcoordinatorcontactedahealth

professionalatthecommunityhealthcentertoinformhimorherofourprojectandto

collectanyrelevantinformationonthecurrentstatusofthecommunity(i.e.ifanyrecent

suicidesorotherdeathshadoccurred,ifanyimportanteventssuchasfeastsor

tournamentswereplanned).Visitswerecancelledifthetimingwasnotappropriate.

TheNunavutSuicideFollow-BackStudy:Howdidwedoit?

TheQaujivallianiqInuusirijauvalauqtunik(Learningfromlivesthathavebeenlived)

projectincludedall120suicidesthatoccurredinNunavutbetweenJanuary1,2003and


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December31,2006.Italsoincluded120livingindividualswhohadclosedatesofbirth,

camefromthesamecommunityoforigin,andwereofthesamegenderasindividualsin

thesuicidegroup.Thepurposeofincludinglivingindividualswiththesamedemographic

backgroundwastocreateagroupwithwhichtocomparesuicidecases,acomparison

group.

The120suicideswereidentifiedbytheNunavutCoronersoffice,andthe120living

individualswereselectedfromtheNunavutHealthcareRegistrationFileaccordingto

theirdateofbirth,communityoforiginandgender.Oncethelivingindividualswere

contacted,theyselectedfamilyandfriendstobeinterviewedforthestudyontheir

behalf.

Oncesuicidegroupsandlivingcomparisongroupshadbeenselectedand

interviewswerescheduled,eachinterviewwasconductedidenticallytoensurethatthere

werenodifferencesinthetypesofinterviewsbeingconductedwiththefamiliesand

friendsoflivingindividualsandthefamiliesandfriendsofindividualswhodiedbysuicide.

Acompletereviewoftherelevantmedicalcharts(whenthefamilygave

permission)andcriminalrecords(whentheindividualhadone)foreachindividualwas

carriedoutinordertoassessmedicalandpsychologicalhistoryforboththesuicideand

comparisongroups.FromMarch2006toJuly2010,atotalof498interviewswereconductedwith

informantsin22communitiesacrossNunavut,eachinterviewtookanaverageoftwoand

halfhourstocomplete.Informantswerefamilymembersandfriendsofindividualswho

diedbysuicidebetween2003-2006,aswellasfamilymembersandfriendsofthoseliving

individualswhowereinvitedtoparticipate.Theysharedinformationaboutthe

individualschildhood,upbringing,lifeexperiences,mentalhealth,druguse,workhistory,

interpersonalrelationships,andanyknownhistoryofsuicideattempts.Wheneverpossible,multipleinterviewswereconductedforeachperson.Thisensuredthatwehad

themostcompleteprofilesofinformationoneachindividualinourstudy.

Aftercompletingthedatacollection,thelengthyprocessoforganizingand

analyzingthedatabegan.Theinterviewerwroteaclinical-biographicalnarrativeforeach


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individual,inwhichdetailsofhisorherlifeweresummarized.Thebiographicalnarrative

describedtheindividualsupbringing,familialrelationships,academicperformance,

romanticexperiences,interpersonalrelationships,occupationallifeanddetailed

informationaboutanypsychiatricsymptoms.Thisnarrative,acopyofthemedical

records,andthecompletedsetofinstrumentsweresenttothecoordinatingcenterfor

furtherprocessing.

AtMcGillUniversity,theinstrumentswereassessedtoensurecompleteness.Any

discrepancyininformationbetweeninstruments(orbetweenaninstrumentandthe

contentofthenarrativesummary)wasidentifiedandresolvedbydiscussionwiththe

interviewer.Thenarrativeswerethenblindedsothatindividualswhodiedbysuicideand

thoseofthecomparisongroupcouldnotbedistinguished(i.e.thecasewasdisguised,

detailsonthecircumstanceofdeathwereremovedandverbswereallchangedtothe

pasttense).Thestandardizedcasenarrative,asummaryofthemedicalrecords,andthe

psychiatricdiagnoseswerethenforwardedtoapanelofresearchcollaboratorsto

validatethepsychiatricdiagnosesthatweregivenbytheinterviewer.Typically,panel

sessionslasted1.5-2hours,and7-10caseswereexaminedpersessiona.Thissignificant

commitmentoftimeiscrucialtoensurethereliabilityofresults.

aForafullreviewofthisstudysmethodology,pleaseconsultChachamovich,E.,Haggarty,J.,Cargo,M.,

Hicks,J.,Kirmayer,L.J.,&Turecki,G.(2013).ApsychologicalautopsystudyofsuicideamongInuitin

Nunavut:Methodologicalandethicalconsiderations,feasibilityandacceptability.InternationalJournalof

CircumpolarHealth,72.


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Thefollowingchartshowshowmanyinterviewswereconductedwithdifferentkindsof

informantsforboththesuicideandcomparisongroups.

Theinterviewsusedinfollow-backdesignshavesomequestionsthatallowpeople

toanswerfreelyatlengthandsomequestionsthatrequirepeopletochooseanswers

fromasetlistofoptions.Open-endedquestionsaresuitabletocollectinformationon

suchtopicsasthepathoflifeeventsandinterpersonalrelationships.Structured

questionnairescangatherinformationaboutbehaviouralpatterns,mentalillness,and

childhoodadversities.

DiagnosingMentalIllness

Inordertomakeformaldiagnosesofmajormentaldisordersandpersonality

disorders,weusedtwocurrentandwellknowntoolscalledtheStructuredClinical

InterviewfortheDSMDisordersIandtheStructuredClinicalInterviewfortheDSM

DisordersII20(SCID-IandtheSCID-II)

19,20,30,54,62.TheDSM,fromwhichthesemeasures

arebased,istheDiagnosticandStatisticalManualofMentalDisorders1049;itisa

comprehensivebookofallmentalillnessesusedaroundtheworldbymentalhealth

professionalsofallkinds6,45,49,53

.

0

10

20

30

40

50

60

70

NumberofIndividuals

FrequencyofInformantsForSuicideandComparison

Groups

SuicideGroup

Comparison

Group


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TheSCID-IassessesmajorpsychiatricdisordersandtheSCID-IIassessespersonality

disorders.Bothtoolshavebeenshowntoprovideconsistentdiagnosesacrosshealthcare

professionals38.Formallyassessingthesedisordersusingthesewell-knownandwidely

usedtoolsisveryimportantbecausepsychiatricandpersonalitydisordersare

consistentlyshowntobeassociatedwithsuicidegestures4,7,32

.

AdditionalMeasures

Psychopathologyalonedoesnotaccountforsuicide11,32,40,47

.Forexample,even

thoughmajordepressionisthemostprevalentdiagnosisamongthosewhodiedby

suicide,thevastmajorityofpeoplewithmajordepressiondonotmakesuicideattempts.

12,17,18,41.Otherfactorsthatindependentlycontributetosuicidecompletionamong

individualswithmajordepressivedisorderincludeimpulsiveness,aggression,family

historyofpsychopathology(mentalhealthproblems),previoussuicideattempts,and

exposuretochildhoodabuse9,16,18,22,39,41,58,61

.Instrumentsandscalestoassessthese

factorswerealsoincluded(seeTable1).

Instrumentsandscaleswerethoroughlyreviewedpriortothestudytoensurethat

theircontentwasappropriatefortheInuitcontext,whenpossible.SomeitemsintheLife

TrajectoryScaleweremodifiedandothersaddedinordertoencompassimportant

aspectsoflifeintheInuitculture,suchaspersonalexperienceswithnon-Inuit,senseof

importanceoftheInuitculture,experienceswithresidentialschools,opportunitiesto

huntandfishand/ortobeconnectedtoInuitculture,abilitytospeakEnglish/Inuktitut/Inuinnaqtun,contactwiththegovernment,andthoughtsforthefutureofNunavut,

amongothers.

Thesescalesareusuallygivendirectlytothepersontheyareabout.Sincewewere

interviewingthefriendsandfamilyoflivingindividualsandindividualswhodiedby

suicide,wemodifiedthescalestobeinthirdperson.Forexample,thequestionHave

youfeltsadlately?,inthesocio-demographicquestionnaire,waschangedtoHas

he/shefeltsadlately?.


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Table1:NunavutFollow-BackStudyDesign

Scale PurposeOfScale

Socio-Demographics Astructuredquestionnairethatgathers

informationabout:

Demographics(ex.Age,RelationshipStatus,Sex,Religion)

AlcoholUse DrugUse Physical/Psychological/SexualAbuse LegalProblems MedicationTakenforPsychiatry

Problems

LifeOverview

Anopen-endedinstrumentthatgathers

informationabouttheinformantsperceptions

oftheindividualslife

FamilyAntecedentsofPsychiatric

Disorders

Astructuredinstrumentthatgathers

informationaboutthehistoryofmentalillness

inbiologicalfamilymembers,andpastsuicidal

behavioursinbothbiologicalandadopted

familymembers.

BarrattImpulsivenessScale6

Astructuredscalethatgathersinformation

abouthowimpulsivesomeoneisinhisorher

behaviouralandemotionalresponsestopeople

andsituations.

BrownandGoodwinLifetimeHistoryof

Aggression13

Astructuredscalethatgathersinformation

aboutthelevelofaggressionapersonshows

wheninteractingwithotherpeopleindifferent

situations.Forexample,itlooksatbehaviour


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inschool,abilitytocooperatewithteachers,

andaggressiveoutburstsatfamilyandfriends.

SuicideHistoryScale10,24

Astructuredscalethatcollectsinformation

aboutprevioussuicideattemptsandideation.

LifeTrajectory56

Anopen-endedinstrumentthatgathers

detailedinformationonchildhood,

adolescence,andadultexperiences.Itlooksat

whereindividualslived,whatkindsoflife

experiencestheyhad,theirpersonallife

(marriage,children,friends),aswellastheir

professionallife(school,jobs,unemployment).

GenealogicalMap3

Adetailedmapofbiologicalandadopted

familymembersandtheirrelationshiptothe

individualinquestion.


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Figure1:ADetailedOverviewoftheNunavutFollow-BackStudyDesign

CoronersOffice

120Cases

NunavutHealthCareRegistrationFile

Interviewersdecision

onpsychopathology

Reviewof

medicalrecords

Informantsinterviewed

aboutthesubjectslife

Familycontactedfor

consent,interview,andto

namefriends

Subjectscontactedfor

consentandtoname

interviewees

Blindpanelreview

Finalpsychiatricdiagnoses

Discussionwiththe

healthprofessional

and/ortheRCMP

Matching

ClinicalVignette

Ablindpanelreviewconsistsofa

groupofprofessionalsthat looksat

thedatafromeachinterview

withoutknowingwhetherthefacts

areaboutalivingindividualoran

individualwhodiedbysuicide.This

ensuresthatalldecisionsreachedregardingdiagnosesarenot

influencedinanywaybyprevious

knowledgebutareexclusively

reachedfromfactualevidence.

Reviewof

medicalrecords


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DemographicCharacteristics

Thefollowingchartsandgraphsshowanswerstoquestionsaskedduringthe

demographicsectionoftheinterviews.RiskFactorsareindividualfactorsthatincrease

apersonschancesofcommittingsuicide.

Sex

Thispiechartshowsthetotal

percentageoffemaleandmale

individualsinthestudy.In

Nunavutbetween2003and2006,moremalesthanfemales

committedsuicide.Thisis

consistentwiththegender

differencesinsuicideamongthe

generalCanadianpopulation.Forexample,ofthetotalnumberofCanadianswho

committedsuicidein2009,77%ofthemweremale15.Therewere196malesand44

femalesinourstudy.99(82.5%)ofsuicidecompletersweremaleand21(17.5%)werefemale.

AgeofDeathfortheSuicideGroup

Thischartshowsthenumberof

individualswhodiedbysuicidein

eachagegroup.Themaximumage

inthestudywas62yearsoldand

theminimumagewas13.The

averageageofindividualswhodied

bysuicidewas23.6yearsold.The 0 10 20 30 40 50 60

13-17

18-27

28-37

38+

NumberofParticipants

AgeinYears

AgeofParticipants(inyears)

PercentageofMalesandFemalesinthe

Study

%ofFemalesintheStudy

%ofMalesinthe

Study


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27

averagedifferenceinbirthdatesbetweenthesuicideandcontrolgroupswas59.27days

(withastandarddeviationof72.2days).

Occupation

Thisgraphdescribestheindividuals

occupationalstatuses.Thesuicide

groupwaslesslikelytohaveajoborbe

astudentatthetimeofdeath.The

comparisongroupwasmorelikelytobe

employedorstudying.

MaritalStatus

Individualswhodiedbysuicide

werealmosttwotimes(1.82

times)morelikelytobesingle

thanthecomparisongroup.On

theotherhand,thecomparison

groupwasmorelikelytobe

marriedorlivingwitha

common-lawpartnerb.Several

otherstudieshavealsoshown

thatlivingaloneorbeingsingle

iscorrelatedwithahigherriskof

bTheitemformaritalstatusontheSocio-DemographicquestionnairewasCivilstatusofS:1)Single,2)

Married/Common-Law,3)Separated,4)Divorced,5)Widow(er),6)DatingPartner,7)DoNotKnow.S

stoodforsubject.Allcategoriesthathadoneornoindividualswerenotrepresentedinthisgraph.

0

20

40

60

80

Worker Student UnemployedNumb

erofIndividuals

OccupationsoftheSuicideand

ComparisonGroupsSuicideGroup

ComparisonGroup

0

20

40

60

80

NumberofIndividuals

MaritalStatusoftheSuicideand

ComparisonGroups

SuicideGroup

Comparison

Group


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28

suicide.Conversely,livingwithapartnerdecreasesoneslikelihoodofonecommitting

suicide45.

LevelofEducation

Individualswhodiedbysuicide

were3.6timesmorelikelyto

havehadlessthan7yearsof

educationthanthecomparison

group.Itispossiblethatschool

dropoutmaybeanindication

thattheindividualislivingin

unfavourableconditions,

whichmayinturnleadto

suicidalbehaviourinthefuture.

JudicialProblems

Thisgraphshowswhetherornot

eachindividualexperiencedlegal

problemsinhisorherlife.The

individualsinthesuicidegroup

were2.21timesmorelikelyto

havebeeninvolvedinlegal

problemscomparedtotheliving

individuals.

0

20

40

60

80

Legal

Problems

NoLegal

Problems

NumberofIndividuals

PastLegalProblemsoftheSuicideand

ComparisonGroups

Suicide

Group

Comparison

Group

0

20

40

60

80

100

Lessthan7

yearsof

education

Upto

JuniorHigh

School

High

schoolor

College

oNot

Know

Number

ofIndividuals

EducationalLeveloftheSuicideand

ComparisonGroups

Comparison

Group

SuicideGroup


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29

Numberofpeoplelivingineachhousehold

OvercrowdingisknowntobeaprobleminNunavut.The2011censusshowsthatthe

averagenumberofpersonsperdwellinginCanadais2.559,whileinNunavutthetotal

numberofpeoplelivingineachindividualshouseholdvariedfrom1to12people.The

averagewas5.4peopleperhousehold.Therewasnosignificantdifferencebetweenthe

numberofpeoplelivinginthesuicidegroupandcomparisongroupshouseholds(average

of5.58peopleand5.23people,respectively).

Adoption

Informantswereaskedwhether

ornottheindividualinquestion

wasadopted.Theinformantcould

answeryes,no,andIdont

know.Thedefinitionofadoption

includedextra-familialadoption

(i.e.,whensomeonefromanother

familyadoptsachild),andintra-

0

20

40

60

80

100

Adopted Not-Adopted

NumberofIndividua

ls

NumberofIndividualsAdoptedorNot

AdoptedintheSuicideandComparison

Groups

Suicide

Group

Comparison

Group

0 20 40 60 80 100 120

From1to3:

From4to6:

From7to9:

From10to12:

NumberofIndidivualsLivinginEachSizeofHousehold

NumberofIndividuals

per

Household

NumberofPeopleLivinginEachHousehold:

SuicideGroupandComparisonGroupCombined


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30

familialadoption(i.e.,whensomeonewithinthefamilyadoptsachild,suchas

grandparents,auntsoruncles,etc.).Inthecomparisongroup,thisinformationwasnot

knownforoneindividual.Unfortunately,wecouldnotcollectinformationaboutwhat

kindofadoptiontookplacefortheseindividuals,noraboutthefamiliestheywere

adoptedinto.Whenstatisticaltestswereapplied,nonotabledifferencewasfoundin

numberofadoptionsbetweenthesuicideandthecomparisongroups.

BiologicalandAdoptedSiblings

Duringtheinterviews,weasked

informantshowmanysiblingsthe

individualshad(thisincludedboth

adoptedandbiologicalsiblings).On

average,theindividualswhodiedby

suicidehad4.1biologicalsiblings,and

2.5adoptedsiblings.

Thecomparisongrouphadanaverage

numberof4.4biologicalsiblingsandan

averageof2adoptedsiblingseach.

Therewasnosignificantdifferencebetweenthesuicideandcomparisongroupsin

numberofbiologicaloradoptedsiblings.

0

10

20

30

40

50

60

0 1 2to4 5to78to10 11+NumberofIndividuals

NumberofSiblings

NumberofAdoptedSiblingsfor

theSuicideandComparison

Groups

Suicide

Group

Comparison

Group

0

10

20

30

40

50

60

70

0 1 2to4 5to7 8to10 11+Numberofindiv

iduals

NumberofSiblings

NumberofBiologicalSiblingsfortheSuicideandComparison

Groups

SuicideGroup

ComparisonGroup


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BiologicalandAdoptedChildren

Informantswereaskedwhetherthe

individualhadeitherbiological

childrenoradoptedchildren.

Theaveragenumberofbiological

childreninthesuicidegroupwas0.88

children(lessthan1childperperson)

and1.62inthecomparisongroup

(almosttwochildrenperperson).

Thecomparisongrouphadmore

biologicalchildrenthanthesuicide

group.

Atthesametime,57%ofindividuals

inthecomparisongrouphadatleast

1child,and34%ofthesuicidegroup

hadatleast1child.Therefore,it

wasnotuncommonforindividuals

inthestudytobeparents.

Thisgraphshowsthenumberof

adoptedchildrenthatindividualsin

eachgrouphad.Ingeneral,veryfew

individualshadadoptedchildren.

0

10

20

30

40

50

60

70

80

90

0 1 2to4 5to7

NumberofIndividuals

NumberofBiologicalChildren

NumberofBiologicalChildrenfor

SuicideandControlGroups

Suicide

Group

Comparison

Group

NumberofBiologicalChildrenforthe

SuicideandComparisonGroups

0

1

2

3

4

5

6

0 1 3 4

Numberofindividuals

NumberofAdoptedChildren

NumberofAdoptedChildrenforthe

SuicideGroupandComparison

Group

SuicideGroup

Comparison

Group

1234


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ChildhoodMaltreatment

Childhoodmaltreatmentisabroadtermthatreferstophysicalabuse,sexual

abuse,emotionalabuse,andneglectduringchildhood.Recentstudiesshowthat

childhoodmaltreatmentisaglobalissuespanningNorthAmerica31,52

,Europe29,and

Asia63.Acrosstheworld,studiesdemonstratethatchildhoodmaltreatmentisarobust

indicatoroffuturenegativeoutcomes.

Victimsofchildhoodabuseattemptorcommitsuicidesignificantlymoreoften

thanthosewhowerenotmaltreatedinchildhood.Additionally,thenumberofsuicides

attemptedincreasesasafunctionofmaltreatmentseverityandpersistence31.Similarly,

thosewhoaremaltreatedinchildhoodarefivetimesmorelikelytopresentsuicide-

relatedbehavioursthanademographicallymatchedcomparisongroup52.

Childhoodmaltreatmentisalsoassociatedwithseveralothernegativeoutcomes

thatmaybelinkedtosuicideandsuicidalbehaviours.Mentalhealthproblems,adult

personalitydisorders,criminalbehaviour,cognitiveandemotionalproblems,drugand

alcoholabusedisorders,riskysexualbehaviours,andobesityproblems29aresignificantly

morecommoninthosewhosufferedfromchildhoodmaltreatmentcomparedtothose

whodidnot42

.

Thenegativeimpactofchildhoodmaltreatmentonmentalhealth,physicalhealth

andsuicidalbehaviourisprofound,prevalent,andgloballysupported.Therefore,itis

imperativetoincluderesearchon

childhoodmaltreatmentwhen

exploringtheriskfactorsforsuicide.

Inourstudyweasked

informantsiftheywereawareof

anyformofchildhood

maltreatment.Specifically,

InformantswereaskedHas_____0

10

20

30

40

50

60

SuicideGroup ComparisonGroup

NumberofIndiv

iduals

NumberofIndividualsWhoWere

MaltreatedinChildhood


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33

everbeenavictimofabusebyanyoneduringthecourseofhisorherlife?fromthe

Socio-DemographicQuestionnaire(SeeTable1).

Informantshadtheoptionofansweringyes,noorIdontknowc.Theabovegraph

showsthenumberofindividualsinthesuicideandcomparisongroupsthatwereabused

inchildhood,basedontheresponsesgiven.Almosthalf(47.5%)ofthesuicidegrouphad

reportedbeingabusedinchildhoodascomparedtoalmostathird(27.5%)ofthe

comparisongroup.

Childhoodabusewasthen

dividedintothreegroupsinour

study.Weaskedwhether

individualshadbeensexually,

physically,and/or

psychologicallyabusedin

childhood.Severalindividuals

hadexperiencedmorethanone

formofabuse,andtherefore

individualsmayberepresented

inmorethanonegroup.21.6%ofthesuicidegrouphadexperiencedphysicalabuseinchildhood,comparedto13.3%of

thecomparisongroup.15.8%ofthesuicidegroupand6.7%ofthecomparisongrouphad

experiencedsexualabuseinchildhood.20%ofthesuicidegroupand10.8%ofthe

comparisongrouphadexperiencedpsychological(emotional)abuseinchildhood.

Significantlymoreindividualsinthesuicidegrouphadbeenphysicallyand/or

sexuallyabusedinchildhoodcomparedtothecomparisongroup.

cBecausethisinformationisbasedontheresponsesgiventothisquestion,childhoodmaltreatmentmay

havebeenunderreported.Informantsmaynothaveknownabouttheabuse,ortheymayhavefelt

uncomfortablesharingthisinformation.

0

5

10

15

20

25

30

NumberofIndivid

uals

TypeofChildhoodMaltreatment

TypesofChildhoodMaltreatment

ExperiencedbytheSuicideand

ComparisonGroups

Comparison

Group

Suicide

Group


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AggressionandImpulsiveness

Informantswereaskedto

completetheBarrattImpulsivenessScale

6(SeeTable1)

foreachindividual.Thisscale

measuresindividuallevelsof

impulsiveness.Theresultsfrom

thisscaleshowedthatthesuicide

groupwasmoreimpulsivethan

thecomparisongroup.

Informantsalsocompletedthe

BrownGoodwinLifetimeHistoryof

Aggressionscale13

(seeTable1)to

assessaggressivebehaviourin

differentsituations.Thisscale

showedthatthesuicidegroupwas

morelikelytohaveahistoryof

aggressivebehaviourstowards

otherindividualsandindifferent

situations.Thisscalealsohasthreedifferentsectionstoassessaggressioninchildhood,

adolescenceandadulthood.Inallthreesections,thesuicidegrouphadhigherlevelsof

aggressionthanthecomparisongroup.

68

70

72

74

76

78

SuicideGroup ComparisonGroupScoresofImpulsivenes

LevelsofImpulsiveness

ScoresofImpulsivenessfortheSuicide

andComparisonGroupsontheBarrattImpulsivenessScale(BIS)

0

20

40

60

80

SuicideGroup ComparisonGroupScoresofAggression

LevelsofAggression

ScoresofAggressionfortheSuicide

andComparisonGroupsontheBrown

GoodwinHistoryofAggressionScale


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MentalHealth

MentalHealthmeansemotionalwell-being,abilitytofaceoneschallengesand

abilitytocopewithstress.Thedefinitionofmentalhealth,accordingtotheWorldHealthOrganization(WHO)is:

Mentalhealthisastateofwell-beinginwhichanindividualrealizeshisor

herownabilities,cancopewiththenormalstressesoflife,canwork

productivelyandisabletomakeacontributiontohisorhercommunity.In

thispositivesense,mentalhealthisthefoundationforindividualwell-being

andtheeffectivefunctioningofacommunity.64

Whensomeonehasintenseemotionalproblems,andtheseproblemsleadto

impairmentincopingwithstress,doinghabitualdailyactivities,ordealingwith

interpersonalproblems,hisorhermentalhealthmaybeaffected.Mentaldisordermeans

thepresenceofmarkedemotionalorbehaviouralproblems,whichcausesignificant

impairmentsinsomeoneslife(adaptedfromtheAmericanPsychiatricAssociation

definition1).


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AccordingtoHealthCanada25,mentalillnessescantakemanyformsandare

groupedintodifferentcategoriesincluding:

Table2:CategoriesofMentalIllness

MoodDisorders Schizophrenia Personality

Disorders

SubstanceAbuse

Disorders

Mooddisorders

affecthowaperson

feels(sadness,for

example)

Schizophrenia

affectshowone

perceivestheworld

(distorted

perceptions)

Personality

disordersaffecthow

apersonseeshimor

herselfinrelation

toothersandhow

thatpersoninteractswith

individualsaround

himorher

Substanceabuse

disordersarerelated

todrinkingordrug

usethatcause

significantproblems

inapersonslife

Althoughsuicideisnotitselfconsideredamentalillness,itisoftentheresultof

someunderlyingmentalillness25.


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MajorPsychiatricIllness

Majorpsychiatricdisorderswereinvestigatedinthisstudyinbothgroups.The

resultsdescribethepresenceofpsychiatricdisordersindifferentmomentsofan

individualslife.First,wegatheredinformationaboutthelast6monthspriortothedeath

bysuicide(inthesuicidegroup)orpriortotheinterview(inthecomparisongroup).We

thengatheredinformationabouteachindividualslifepriortothelast6months(i.e.,

fromadolescenceorchildhooduntil6monthspriortothedeathortheinterview).The

objectiveofaskingaboutdistinctmomentsinanindividualslifeistounderstandifthe

mentalproblemsthatcontributedtothesuicideattemptsstartedearlierinthe

individualslife,wererecentproblems,orexistedbothcurrentlyandinthepast.These

disorderswereassessedusingtheStructuredClinicalInterviewforDSMDisorders(SCID-I)

(SeeDiagnosingMentalIllness)20,38

Itisimportanttonotethat,whilethenumberofindividualsdiagnosedwiththese

disordersinthelast6monthsandpriortothelast6monthsisreportedseparately,

individualsmayfallintobothgroups.Therefore,individualsmayhavehadthedisorder(or

multipledisorders)bothrecentlyandinthepast.

Fordiagnosesofmajorpsychiatricillnessinthepast6months,wefoundnotable

differencesbetweenthesuicideandcomparisongroupsinnumbersofindividuals

diagnosedwithmajordepressivedisorder,cannabisabuseordependenceandalcohol

abuseordependence.Theseresultsweresuchthatthesuicidegroupwasmorelikelyto

bediagnosedwitheachofthesedisordersthanthecomparisongroup.

Whilemoreindividualswhodiedbysuicidewerediagnosedwithmajordepressive

disorderinthisstudy,ratesofmajordepressivedisorderwerehigherthanthegeneral

Canadianpopulationforbothgroups.Approximately8%ofthegeneralCanadian

populationwillexperiencemajordepressionatsometimeintheirlives,whereasinour

study,61%ofsuicidecompletersand24%ofthecomparisongroupwerediagnosedwith

majordepressivedisorder.Therefore,theratesofmajordepressivedisorderamongInuit

inourstudywerehigherthanthenationalaverage.


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38

Individualswerealsoscreenedforadjustmentdisorder,bipolartypeIdisorder,

schizophrenia,otherdrugabuseordependence,socialphobia,obsessive-compulsive

disorder,pathologicalgambling,andpost-traumaticstressdisorderbothinthelastsix

monthsandpriortothelastsixmonths.Averysmallnumberofindividualswere

diagnosedwiththesedisorders(lessthanfivepeoplepergroup)andthenumberof

peoplediagnosedwiththesedisordersdidnotnotablydifferbetweenthesuicideand

comparisongroups.

Severaloftheindividualsdiagnosedwithamajorpsychiatricdisorderwerealso

diagnosedwithatleastoneothermentaldisorder.Amongtheindividualsinthesuicide

groupthathadonepsychiatricdiagnosis,71.8%wasdiagnosedwithanothermental

disorder.Inthecomparisongroup,56.5%ofthosewithonepsychiatricdiagnosiswere

diagnosedwithanothermentaldisorder.Therefore,itmaybetheinteractionofmultiple

mentaldisordersthatincreasedindividualriskforsuicide.WhileaccurateCanadian

statisticswerenotavailablewithwhichtocomparetheserates,arecentUSstudy

reportedthat54%ofthosewithalifetimehistoryofatleastonementalillnessalsohad

atleastoneothermentalillness26.Itindicatesthatratesofcomorbidity(havingmore

thanonepsychiatricdiagnosis)inthecomparisongrouparecomparabletoUSrates.

However,thoseinthesuicidegrouparemarkedlyhigher.Theratesofmajorpsychiatricillnessfoundinthisstudywerehigherthaninthe

generalCanadianpopulation.Nationally,about20%ofCanadianswillhaveanepisodeof

mentalillnessduringtheirlifetime,withmanyoftheseillnessesfallingunderthemajor

psychiatricillnesscategory26.Morespecifically,approximately8%ofthegeneralCanadian

populationwillexperiencemajordepressionatsometimeintheirlives,whereasinour

study61%ofsuicidecompletersand24%ofthecomparisongroupwerediagnosedwith

majordepressivedisorder.Therefore,theratesinofmajordepressivedisorderamongInuitinourstudywerehigherthanthenationalaverage.


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Amongthosediagnosedwithmajorpsychiatricdisorderspriortothelast6

months,wefoundsignificantdifferencesinmajordepressivedisorderandcannabisabuse

ordependencebetweenthesuicideandthecomparisongroups.Thenumberof

individualsdiagnosedwithalcoholabuseordependencepriortothelast6months,

however,didnotsubstantiallydifferbetweenthetwogroupsd.

dTherewasstillarelativelyhighnumberofindividualsdiagnosedwiththisdisorder(44%ofthesuicidegroupand38%ofthecomparisongroup)buttherewasnostatisticaldifferencebetweengroups;

thereforetheseresultsdonotshowthatlifetimealcoholabuseordependenceisariskfactorforsuicidein

ourstudy.

0

10

20

30

4050

60

70

80

NumberofIndividuals

NumberofIndividualsDiagnosedwithLifetime(priortothelast6

months)MajorPsychiatricIllnesses

Suicide

Group

Comparison

Group


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40

MajorDepressiveDisorder(MajorDepression)

Inthelast6months,thesuicidegroup

wasmorelikelytohavemajor

depressivedisorderthanthe

comparisongroup.54.1%ofthesuicide

groupand8.3%ofthecomparison

groupwerediagnosedwithmajor

depressivedisorderinthelast6months

oftheirlives.

Thisisconsistentwithpreviousstudies

showingthatmajordepressivedisorderisassociatedwithsuicide17.

Inadditiontohavingmajor

depressivedisorderinthelast6

months,someindividualshadmajor

depressivedisorderdiagnosedprior

tothepast6months.60.8%ofthe

suicidegroupand24.1%ofthe

comparisongroupwasdiagnosed

withmajordepressivedisorderprior

tothelast6months.

0

20

40

60

80


NumberofIndividuals

NumberofIndividualswithMajor

DepressiveDisorderintheSuicide

andComparisonGroups(Last6Months)

0

20

40

60

80


NumberofI

ndividuals

NumberofIndividualswithMajor

DepressiveDisorderintheSuicideand

ComparisonGroups(PriortotheLast

6Months)


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CannabisDependenceorAbuse

Eachindividualwasassessedforcannabis

dependenceorabusedisorders.Inthelast6

months,57.5%ofthesuicidegroupand

25.8%ofthecomparisongroupwas

diagnosedwithcannabisdependenceor

abuse.Therefore,thesuicidegroupwasmore

likelytohaveacurrentcannabisdependence

orabusedisorder.

Wethenassessedthelifetimepresenceof

cannabisdependenceorabusedisorders

(priortothelast6months).59.1%ofthe

suicidegroupand35.8%ofthecomparisongroupwerediagnosedwithcannabisabuse

disorderspriortothelast6months.

Sinceindividualsinthesuicidegroup

werelikelytoalsohaveacannabis

abuseordependencedisorderpriorto

thelastsixmonths,thecannabis

dependenceorabusedisorderin

theseindividualsmayhavebeen

presentforalongperiodoftime.

0

10

20

30

40

50

60

70

80

SuicideGroup Comparison

Group

NumberofIndividuals

NumberofIndividuals

DiagnosedwithCannabis

Dependence/Abuse(IntheLast6Months)

0

10

20

30

40

50

60

70

80


NumberofIndividuals

NumberofIndividualsDiagnosed

withCannabisDependence/Abuse

(PriortotheLast6Months)


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42

AlcoholDependenceorAbuse

Individualswereassessedfor

alcoholdependenceorabuse

disordersbothinthelast6months

andpriortothelast6months.The

suicidegrouponlynotablydiffered

fromthecomparisongroupin

diagnosesofalcoholabuseor

dependenceinthelastsixmonths.

37.5%ofsuicidegroupand17.5%of

thecomparisongrouphadalcohol

abuseordependence.Thisindicates

thatalcoholabuseordependencemaybeamoreacuteriskfactorforsuicide.

WhilenostudiestodatehaveexaminedoverallCanadiandrugandalcoholabuse

anddependencerates,theresultsfromtheAmerican2011NationalSurveyonDrugUse

andHealth60foundthat6.5%ofindividualsovertheageof12yearsoldhavehadan

alcoholabuseordependencedisorderatsomepointintheirlives.Theseratesarelower

thanthoseofeitherthesuicidegroup(37.5%)orthecomparisongroup(17%)onalcohol

abuseordependencedisorders.

Similarly,theAmericanrateforcannabisabuseanddependencewas1.6%of

individualsover12yearsold.Thisrateislowerthanboththesuicidegroup(59.1%)and

thecomparisongroup(35.8%).Therefore,bothalcoholandcannabisabuseand

dependencedisorderratesarehigheramongInuitinourstudythannationalAmerican

rates60.

0

10

20

30

40

50


NumberofIndividuals

NumberofIndividualswithAlcohol

Abuse/DependenceDisorders(inthePast6Months)


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PersonalityDisorders

Personalitydisordersarecharacterizedbydifficultiesinteractingwithandrelating

tootherpeopletosuchanextentthatithasasignificantimpactontheindividualslife.

Thesearesevereandpersistentdisordersthatmayinteractwithmajorpsychiatric

illnesses.Specificallywefoundasignificantdifferencebetweenthesuicidegroupandthe

comparisongroupsinborderlinepersonalitydisorder,conductdisorder,andantisocial

personalitydisorder;suchthatthesuicidegroupwasmorelikelytohavethesedisorders

thanthecomparisongroup.

Participantswerealsoscreenedforpassiveaggressivedisorder,obsessive-

compulsivepersonalitydisorder,depressivedisorderandavoidantpersonalitydisorderin

0

5

10

15

20

25

N

umberofIndividuals

IndividualsDiagnosedwithPersonalityDisordersintheSuicideand

ComparisonGroups

SuicideGroup

Comparison

Group


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44

someindividuals.Thesedisorderswereonlyrarelydiagnosed(lessthantwelvepeopleper

groupmaximum)andtheratesofthesedisordersdidnotnotablydifferbetweenthe

suicideandcomparisongroups.

Thosediagnosedwithpersonalitydisorderswerealsolikelytohaveanother

mentaldisorder,especiallyamongthesuicidegroup.89%ofthesuicidegroupand29%of

thecomparisongrouphadmorethanonementaldisorder.

BorderlinePersonalityDisorder

Borderlinepersonalitydisorderischaracterizedbyaprolongeddisturbanceof

behaviouralandinterpersonal

functioningmarkedbyunusual

variabilityandseverityofmoods

(ex.extremedepressionor

inappropriatelyextremeanger).

Othercharacteristicssuchas

impulsivityinself-damaging

behaviours(recklessdriving,

substanceuse),persistent

feelingsofemptinessor

boredom,andfranticeffortsto

avoidabandonmentarealsocommon.Thosediagnosedwithborderlinepersonality

disorderoftenhavedisturbancesanduncertaintiesregardingtheiridentity(values,

sexual-orientation,goals,anddesiredfriends37).Thesecharacteristicsmaysecondarily

affecthowthepersonthinksandinteractswithothers44.19.2%ofthesuicidegroupand

3%ofthecomparisongroupwerediagnosedwithborderlinepersonalitydisorder.

0

5

10

15

20

25


Nu

mberofIndividuals

NumberofIndividualsDiagnosedwithBorderlinePersonalityDisorderinthe

ComparisonandSuicideGroups


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ConductDisorder

Conductdisorderischaracterizedbya

prolongedpatternofbehaviourthat

seriouslyviolatesage-appropriatenorms

andrulesatyoungages(late

childhood/earlyadolescence)46.

Forexample,adolescentsdiagnosedwith

conductdisorderareoftenphysically

aggressivetowardspeopleoranimals,

emotionallyabusivetowardspeople,or

forceotherstoengageinbehavioursthey

areunwillingtoengagein(ex.forcedsexualactivity).Thosediagnosedarealsolikelyto

stealordestroyotherspropertyandpathologicallylie55.15%ofthesuicidegroupand3%

ofthecomparisongrouphadconductdisorder.

AntisocialPersonalityDisorder

Antisocialpersonalitydisorderissimilar

toconductdisorder,itischaracterized

byapervasivepatternofbehaviourthat

violatestherightsofothersanddefies

rulesandnorms2,43

.Forexample,those

diagnosedwithantisocialpersonality

disorderexhibitacompletedisregard

forothers(theirfeelings,property,or

needs),egocentricity,impulsivity

(failuretoplanforthefuture,failureto

keepajoborstayinschool),irritability,

aggressiontowardsothersand/oranimals,repeatedlying,manipulationofothersforown

0

5

10

15

20

NumberofIndividuals


withConductDisorderinthe

ComparisonandSuicideGroups

0

5

10

15

20

SuicideGroup ComparisonGroupNumber

ofIndividuals


withAntisocialPersonality

DisorderintheComparisonand

SuicideGroups


46/56

46

pleasure,inabilitytoformmeaningfulrelationshipsandanoverallantisocialdisposition37.

Thosediagnosedoftencommitcrimesandareunaffectedbytheresultingpunishment.

Similarly,thosediagnoseddisplaynoremorseorguiltfortheiractions.Antisocial

personalitydisorderbeginsinearlyadolescenceandcontinuesintoadulthood37.

Therefore,antisocialpersonalitydisordercanonlybediagnosedinadultsbyassessing

theirbehaviourfromchildhood2.14.2%ofthesuicidegroupand7.5%ofthecomparison

grouphadantisocialpersonalitydisorder.


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PsychiatricCare

Inthisstudy,wewantedtofindoutwhatsortofmentalhealthcareindividuals

receivedwhentheyneededitduringtheirlife.Thisinformationwasgatheredbyasking

theinformantsabouteachindividualshistoryandbycheckingtheindividualsmedical

recordswhenpermissionwasgrantedatthehealthcentersorregionalhospitals.

Theinformantswereaskedwhethertheindividualshadbeenhospitalizedfor

psychiatricreasons,oriftheyhadbeenonpsychiatricmedicationatanypointduring

theirlives.Thefollowingpagescharttheanswerstothosequestions.

Ingeneral,medicationforpsychiatricproblemsisprescribedwhenthehealth

professionalconsidersthatsomeoneisundersevereemotionalstress.Also,thehealth

professionalmustbelievethatthestressiscausingthatpersonsignificantsufferingand

impairment.

Hospitalizationforpsychiatricproblemsisusuallyrecommendedwhensomeoneis

atimmediateriskofharminghimself/herselforothers(i.e.,suicidalideation,aggressive

thoughts,symptomsofwithdrawalfromdrugs,orseveredepression).

PsychiatricMedication

Amongthoseindividualswhodiedby

suicide,17.8%hadbeenonsomekind

ofpsychiatricmedicationinthepast.

Amongthecomparisongroup,7.8%

hadtakenpsychiatricmedication.

Theindividualswhodiedbysuicide

weremorelikelytohaveused

psychiatricmedicationthanthosein

thecomparisongroup(1.5times

morelikely).However,82.2%ofthe

0

20

4060

80

100

120

Prescribed

Psychiatric

Medication

Not

Prescribed

Psychiatric

Medication

oNotKnow

NumberofIndividualsWhoHad

TakenPsychiatricMedicationinthe


Comparison

Group

SuicideGroup

Numbero

fIndividuals

Taken

Medication

Never

Taken

Medication


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48

suicidegrouphadnevertakenmedicationforamentalillness.

PsychiatricHospitalization

Psychiatrichospitalizationoccurswhensomeoneisundergreatdistressandthe

healthprofessionalbelievesthatplacingthepersonunderintenseassistanceand

observationisnecessary.Being

hospitalizedusuallyindicatesthat

someoneisfacingaverydifficult

situationandhisorhermental

stateisalteredbyit.

Amongthosewhocommitted

suicide,17%werehospitalized

beforepassingaway.Inthe

comparisongroup,7.5%hadbeen

hospitalized.Thesefigures

corroboratethefactthatthosewhoendedupcommittingsuicidepresentedsignsof

importantmentalsuffering(ordisorder)priortotheact.Thehospitalizationsmayhave

occurredlongbeforetheact,orimmediatelybefore.

0

20

40

60

80

100

120

Yes No DoNotKnow

NumberofIndividuals

PriorPsychiatricHospitalizationfor


Suicide

Group

Comparison

Group


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49

NumberofHospitalizations

Thisgraphrepresentshowmanytimesthesuicideandcomparisongroupswere

hospitalizedforpsychiatricreasons.Itisimportanttohighlightthattheseindividualswere

seenbyahealthcareprofessionaland,therefore,wereprescribedhospitalizationor

medicationbythathealthprofessional.

7.5%ofthesuicidegroupwasonlyhospitalizedonce.However,9.1%was

hospitalizedmorethanonce,whichindicatesthattheproblemwaspresentandenduring

foralongerperiodoftime.4.1%ofthecomparisongroupwashospitalizedonce,and

3.3%werehospitalizedmorethanonce.

0

2

4

6

8

10

1Hospitalization 2Hospitalizations 3Hospitalizations 4+HospitalizationsNumberofIndividuals

NumberofHospitalizationsforSuicideandComparisonGroups

SuicideGroup

Comparison

Group


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50

Limitations

Thisstudyhaslimitationsthatareinherentinthepsychologicalautopsy

methodology.Eventhoughthisapproachisconsideredtobeoneofthemostvalidand

reliable,someinformantsmaynothavebeenabletoprovidethenecessaryinformation

becauseitpertainedtoinnerfeelingswhichmaynothavebeenwellcommunicatedto

theresearcher.Thismaycontributetounderreportingofsomediagnosticcriteria.An

overestimationofsymptomsthatwerenotdeemedsignificantpriortothesuicidemay

alsooccurasanattempttoconstructmeaningofthedeath.Finally,thementalstateof

theinformantwasnotformallyassessed,anditcouldalsohaveplayedaroleintheir

responses.Nevertheless,thesameapproachwasusedforallinformantsduringthe

interviews,whichminimizestheoccurrenceofsystematicbias.

Theutilizationofstandardizedinstruments(thatwereadaptedwhenpossible)has

bothadvantagesanddisadvantages.Itensuresthatresultsarereliableandaccuratesince

thoseinstrumentshavebeentestedandshowntohavesatisfactorymeasurement

properties.Ontheotherhand,usingstandardizedinstrumentsmaylimitthe

comprehensivenessofthestudygiventhatinstrumentsfocusonknowncharacteristics

andcouldpotentiallyoverlookotherimportantfactors.

Finally,thisstudyaimedtoidentifyriskandprotectivefactorsfordeathsby

suicide.Itwasnotabletoscientificallyexplorethecausesofthehighratesofmental

healthdisorders,childhoodadversitiesorimpulsive-aggressivebehaviors.Thesemental

healthsymptomsaredeterminedbymultiplefactors,andnotonesinglecause.


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51

Conclusion

TheQaujivallianiqinuusirijauvalauqtuniksuicidefollow-backstudyfindingsreinforce

theconclusionsofthePartnersintheNunavutSuicidePreventionStrategywhichwere:

1. Therapidincreaseinsuicidalbehaviourinrecentdecades,especiallyamongyoungpeople,isprobablytheresultofachangeintheintensityofsocialdeterminants

amongthemtheintergenerationaltransmissionofhistoricaltraumaanditsresults

(increasedratesofemotional,physical,andsexualabuse,violence,substanceabuse,

etc.).

2. Sincedifficultlifeexperiencesareassociatedwiththeonsetofmentaldisorders(particularlyifsubstanceabuseisincludedinthedefinitionofmentaldisorder),itis

reasonabletodeducethatthereareelevatedratesofmentaldisordersinNunavut

society48.

Itisimportanttonotethatwhileanindividualmayhaveoneormoreriskfactorsfor

suicideoccurringintheirlife,thisdoesnotpredisposethemtosuicide.Thesamecanbe

saidforprotectivefactors;havinganumberofprotectivefactorspresentinoneslifedoes

notguaranteethattheywillnotbeatriskforsuicide.Thereportindicatesthattherisk

factorsofunemployment,childhoodmaltreatment,sexualabuse,impulsiveness,

aggression,currentandlifetimediagnosesofmajordepressivedisorder,alcoholabuseor

dependenceandcurrentorpastcannabisabuseordependenceareriskfactorsforInuit

suicideinNunavut.Assuch,thereisanurgentneedtoprovidebetterqualitymental

healthcare,counsellingandsubstanceabuseservicesforInuitinNunavut.

Withoutthosewhoparticipatedinthestudywewouldnothavethedatatoguide

futurepolicyandprogramdecisions,ortoaccuratelyidentifytheriskfactorsforInuit

suicideinNunavut.WerecognizehowdifficultanissuesuicideistotalkaboutinNunavut,

thereforewewishtoacknowledgethecourageandwillingnessofNunavummiutwho

participatedintheQaujivallianiqinuusirijauvalauqtuniksuicidefollow-backstudy.The


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52

personalstoriesandinformationthatyouprovidedwereinstrumentalincapturingan

accuratereflectionoflivesthathavebeenlived.Wewillhonouryourparticipationby

usingtheinformationthatyouprovidedtoaddresstheidentifiedriskandprotective

factorsspecifictoInuitofNunavut.

ItisourhopethatthisreportwillassistinachievingthevisionoftheNunavutSuicide

PreventionStrategy,whichisaNunavutinwhichsuicideisde-normalized,wheretherate

ofsuicideisthesameastherateforCanadaasawholeorlower.ThiswillbeaNunavut

inwhichchildrenandyouthgrowupinasaferandmorenurturingenvironment,andin

whichpeopleareabletolivehealthy,productivelivesbecausetheyhavetheskillsneeded

toovercomechallenges,makepositivechoices,andenterintoconstructiverelationships.

ThiswillalsobeaNunavutinwhichfamilies,communities,andgovernmentswork

togethertoprovideawide-reachingandculturallyappropriaterangeofservicesforthose

inneed48

.


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