Religion and Suicide Risk: a Systematic Review

Archives of Suicide Research, 20:1–21, 2016 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2015.1004494

Religion and Suicide Risk: A Systematic Review

Ryan E. Lawrence, Maria A. Oquendo, and Barbara Stanley

Although religion is reported to be protective against suicide, the empirical evidence is inconsistent. Research is complicated by the fact that there are many dimensions to religion (affiliation, participation, doctrine) and suicide (ideation, attempt, completion). We system- atically reviewed the literature on religion and suicide over the last 10 years (89 articles) with a goal of identifying what specific dimensions of religion are associated with specific aspects of suicide. We found that religious affiliation does not necessarily protect against suicidal ideation, but does protect against suicide attempts. Whether religious affiliation protects against suicide attempts may depend on the culture-specific implications of affiliating with a particular religion, since minority religious groups can feel socially isolated. After adjusting for social support measures, religious service attendance is not especially protective against suicidal ideation, but does protect against suicide attempts, and possibly protects against suicide. Future qualitative studies might further clarify these associations.

Keywords religion, spirituality, suicide, suicidal ideation, suicide attempt

INTRODUCTION We conducted a systematic review of the literature with the goal of identifying Although religion is reported to be protec- what specific dimensions of religiosity are tive against suicide, (Koenig, 2009; Perlman, associated with specific aspects of suicide. Neufeld et al., 2011; Suicide Prevention We hypothesized that religious affiliation Resource Center, 2003), the empirical evi- and frequent attendance at religious services dence is inconsistent, with some studies would protect against suicide attempts, but reporting it to be protective (Dervic et al., not suicidal ideation, reflective of clinical 2004), others finding it a risk factor (Zhao experience wherein persons say, ‘‘I think et al., 2012), and still others reporting it about suicide, but would never do it unrelated to suicide risk (Le, Nguyen, Tran, because of my religion.’’ A second goal & Fisher, 2012). The relationship between was to identify whether religion is ever religion and suicide is complicated because associated with increased suicide risk, for both religion and suicide are complex con- instance if a person feels rejected by God structs. Religion has many dimensions or by the community. (affiliation, participation, doctrine) as does suicide (ideation, attempt, completion). METHOD

In October 2013 we searched Pubmed (all Supplemental data for this article can be accessed on fields) using the terms ‘‘suicide AND religi- the www.tandfonline.com/usui. on’’ (n ¼ 387 articles), ‘‘deliberate self-harm

1 Religion and Suicide Risk

AND religion’’ (n ¼ 1 article with original they have been operationalized in a variety data and two review articles), ‘‘suicide of ways, ranging from single-item measures AND spirituality’’ (n ¼ 15 additional (e.g., religious affiliation: yes=no (Dervic articles), and ‘‘deliberate self-harm AND et al., 2004)) to more complex scales (e.g., spirituality’’ (n ¼ 0 articles). Results were 20-item Spiritual Wellbeing Scale (Ellison, limited to English language articles pub- 1983)). For the purposes of this review, lished within the last 10 years. we included any characteristic that was We focused on articles that measured described in the article as religious or spiri- suicidal ideation (seriously thinking about tual. One article was excluded because the attempting suicide), suicide attempt (non-fatal religious variable was ‘‘being possessed by self-harm accompanied by any intent to die), spirits,’’ and three articles were excluded and suicide (intentional self-harm resulting in because they utilized religious characteris- death). No article was excluded owing to tics of large populations, rather than differences in terminology. individuals. Religion and spirituality are concepts The final review included 89 articles. A that elude strict definition. Nevertheless, total of 316 articles were excluded for

TABLE 1. The table Lists Articles Excluded from the Current Literature Review on Religion and Suicide. Pubmed was Searched (October 2013). Search Terms were: Suicide AND Religion, Deliberate Self-Harm AND Religion, Suicide AND Spirituality, Deliberate Self-harm AND Spirituality. The Search was Limited to Articles Published Within the Last 10 years, and Written in English. A Total of 405 Articles were Retrieved, 89 Articles were Reviewed, 316 Articles were Excluded for Reasons Described here

No original Different Analytic Other data (136) topic (100) limitations (77) exclusions (3)

Review article Assisted suicide= No religion variable (18) Article not in (68) Euthanasia (70) English (1) Essay (52) Suicide terrorism (15) Religion variable was ‘‘spirit possession’’ (1) Incorrect citation (1) Commentary Beliefs about suicide in Did not measure suicidal ideation, attempt or Outside 10-year (14) general (9) suicide (18) frame (1) Annotated Beliefs about people Case report or series (16) bibliography who self-harm (1) (1) Not a formal Rational suicide (2) Did not compare suicide risk across religion (12) study (1) or spirituality (5) variables Coping after a suicide Did not report results from comparing suicide (2) risk by religion (1) Talking with patients No statistical test for significance (1) about suicide (1) Did not use individual-level religion data (4) Religion=spirituality variables were not sufficiently described for evaluation (1)

Case series described religious characteristics of the cases, but did not compare them with non-cases or with the general population.

2 VOLUME 20 NUMBER 1 2016 R. E. Lawrence et al. reasons described in Table 1. In this review mask important differences between we focus primarily on religious affiliation specific affiliations. Each population stud- and religious service attendance, since these ied is associated with some limited general- were by far the most commonly used izability (e.g., advanced cancer patients, US religious variables. The relationship between Air Force personnel, Malaysian adults). The suicide risk and other religious variables is studies also do not account for whether a summarized in the supplementary materials. particular religious affiliation is a majority or minority group, an important variable given that those who are from minority RELIGIOUS AFFILIATION AND groups may feel less supported and more SUICIDAL BEHAVIOR isolated from mainstream culture. Many other studies have non-significant findings Religious Affiliation and Suicidal Ideation (c.f. Tables 1–2). Overall, the data do not support a simple conclusion that religious Two studies in the United States sug- affiliation protects against suicidal ideation. gest persons with a religious affiliation have less suicidal ideation than unaffiliated persons. Dervic et al. interviewed 371 Religious Affiliation and Suicide Attempts depressed inpatients in the United States, and found that unaffiliated persons had Several studies have suggested religious higher scores on the Scale of Suicidal Idea- affiliation protects against suicide attempts. tion (mean 16.0, n ¼ 61) compared to In a United States sample Dervic et al. religiously affiliated persons (mean 12.9, (n ¼ 200 depressed bipolar patients) found n ¼ 305, bivariate p ¼ 0.04) (Dervic et al., that suicide attempts were more common 2004). Similarly, Spencer et al. interviewed among patients with no religious affiliation 700 adults with advanced cancer in the (total n ¼ 51, 80.4% had a suicide attempt) United States, and found that suicidal idea- compared to affiliated patients (total tion was more common among unaffiliated n ¼ 641, 63.1% had a suicide attempt, patients (10 of 34, 29.4%) than religiously bivariate p ¼ .023). Moreover non-affiliated affiliated persons (51 of 661, 7.7%) patients had more suicide attempts on aver- (Spencer, Ray et al., 2012) (Table 2). age (2.3) than affiliated patients (1.6, bivari- However, religious affiliations do not ate p ¼ .034). The relationship between all provide the same protection against sui- religious affiliation and suicide attempt, cidal ideation. In a large study of US Air however, was not significant after adjusting Force personnel (n ¼ 52,780), rates of suici- for Moral and Religious Objections to Sui- dal ideation were higher than average cide (Dervic, et al., 2011; see also Dervic among non-Christian religions (Snarr, Hey- et al., 2006; (Dervic et al., 2004). man, & Smith Slep, 2010). In Malaysia Similar results were found in Europe. (n ¼ 20,552), suicidal ideation rates were Kralovec et al. surveyed Austrian lesbian, higher among Hindus than Christians gay, or bisexual adults (n ¼ 219 had a (Maniam et al., 2013), and in Taiwan religious affiliation, n ¼ 139 did not) along (n ¼ 4,000) rates of suicidal ideation were with heterosexual matched controls higher among Christians than Buddhists (n ¼ 215 had a religious affiliation, n ¼ 52 (Fang, Lu, Liu, & Sun, 2011) (Table 3). did not). Those with a religious affiliation These studies do not conclusively reported fewer suicide attempts than those answer the question of whether religious with no religious affiliation; both in the whole affiliation is protective against suicidal idea- sample (6% versus 15%,OR2.92,CI tion. Pooling all religious affiliations may 1.65–5.18) and in the lesbian, gay, or bisexual

ARCHIVES OF SUICIDE RESEARCH 3 Religion and Suicide Risk

TABLE 2. Quantitative Studies Comparing Suicide Risk for Affiliated Versus Unaffiliated Persons

Suicidal Author/Date Location Sample ideation Suicide attempt

(Dervic et al., 2004) United N ¼ 371 depressed Increased if Increased if States inpatients unaffili- unaffiliated ated (Tran Thi Thanh, Tran et al., Vietnam N ¼ 2,260 persons NS (Not 2006) Signifi- cant) (Zhang, Jia, Jiang, & Sun, 2006) China N ¼ 74 suicide attempters, NS 92 accidentally injured emergency room patients (Huguelet et al., 2007) Switzerland N ¼ 115 adults with NS schizophrenia N ¼ 30 non-psychotic inpatients with prior suicide attempt (Sisask et al., 2010) 7 countries N ¼ 2,819 suicide Results varied by attempters, N ¼ 5,484 countryx controls (Kukoyi, Shuaib, Jamaica N ¼ 332 adolescents in NS Increased if Campbell-Forrester, Crossman, school unaffiliated & Jolly, 2010) (Dervic et al., 2011) United N ¼ 200 inpatients with NS Increased if States bipolar depression unaffiliated (Young, Riordan, & Stark, 2011) Scotland N ¼ 2,157 adolescents NS NS (Kralovec et al., 2012) Austria N ¼ 358 lesbian, gay, or NS Increased if bisexual persons unaffiliated N ¼ 267 heterosexual matched controls (Spencer, Ray et al. 2012) United N ¼ 700 adults with Increased if States advanced cancer unaffiliated (Le, Nguyen et al. 2012) Vietnam N ¼ 11,117 persons NS (Carli et al., 2014) Europe N ¼ 2,631 nonfatal suicide Unaffiliated had attempts more serious attempts (Martiny, de Oliveira e Silva, Brazil N ¼ 69 hemodialysis Affiliation decreased risk (only in Neto, & Nardi, 2011) patients the absence of major depression)y (Benute et al., 2011) Brazil N ¼ 268 women with Increased if unaffiliated y high-risk pregnancy

(Continued )

4 VOLUME 20 NUMBER 1 2016 R. E. Lawrence et al.

TABLE 2. Continued

Suicidal Author/Date Location Sample ideation Suicide attempt

(Shim & Park, 2012) Korea N ¼ 400 cancer patients Increased if unaffiliatedy (Zhao et al., 2012) China N ¼ 1,177 undergraduates Affiliation decreased suicide risk for those who believe in socialism. Affiliation increased suicide risk for those who do not believe in socialism.y (Stratta et al., 2012) Italy N ¼ 426 earthquake NSy victims, N ¼ 522 controls

Result was not significant in the final model adjusting for all covariates. yAuthors combined suicidal ideation and attempt. x Affiliation protected against suicide attempts in Estonia, but was a risk factor in South Africa. Affiliation was not significant in Brazil and Vietnam. In India, Sri Lanka, and Islamic Republic of Iran all respondents reported a religious denomination. Additionally Zhang, Conwell, Zhou, & Jiang (2004) compared 66 completed suicides (psychological autopsy) with 66 matched controls and found no significant association between affiliation and suicide.

TABLE 3. Quantitative Studies Addressing Suicide Risk by Religious Affiliation

Completed Author/Date Location Sample Suicidal ideation Suicide attempt suicide

(Aghanwa, Fiji N ¼ 128 adult NS 2004) suicide attempters (Birkholz et al., United N ¼ 49 hospice NS 2004) States patients (Sidhartha & India N ¼ 1,205 Higher among Hindus Jena, 2006) adolescents versus other religions (combined Muslim, Christian, Jain, and Sikh) (Snarr et al., United 52,780 Air Force Higher among NS 2010) States personnel non-Christian religions. Reduced among Christians who are Evangelical Christian, female Roman Catholic, and male ‘‘other Protestant’’

(Continued )

ARCHIVES OF SUICIDE RESEARCH 5 Religion and Suicide Risk

TABLE 3. Continued

Completed Author/Date Location Sample Suicidal ideation Suicide attempt suicide

(Maniam et al., Malaysia 20,552 adults Higher for Hindus 2013) than Christians. Buddhists and Muslims did not differ significantly from Christians. (Fang, Lu, Liu, Taiwan 4,000 adults recruited Higher among Higher among & Sun, 2011) from religious Christians than Christians than services Buddhists. Buddhists. Catholics and Catholics and Taoists did not Taoists did not differ significantly differ significantly from Christians.y from Christians.y (Gal et al., Israel Interviews with 469 NS Higher among Jews Higher risk 2012) Muslims & 3,997 than Muslims among Jews about Jews than ideation, records Muslims of 20,480 suicide attempts, records of 1,843 suicides (Kohler & Bulgaria Census data and Christians Preston, death records had 2011) higher risk than Muslims (Chan et al., Malaysia 75 consecutive NS in multivariate 2011) psychiatric logistic regression inpatient admits for major depression (Klein, Switzerland Death records from Roman Bischoff, & 1995–2007 Catholics Schweitzer, had 2010) lower suicide rate than Protes- tants

(Continued )

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TABLE 3. Continued

Completed Author/Date Location Sample Suicidal ideation Suicide attempt suicide

(Foo, Alwi, Malaysia 139 undergraduates NS Ismail, Ibrahim, & Osman, 2012) (Cooper-Kazaz, Israel 49 suicide NS 2013) attempters, 389 non-attempters evaluated by CL psychiatry service

The dataset did not include a group with no religious affiliation. yThe authors separated ‘‘Catholic’’ and ‘‘Christian’’ without explanation. NB: In Uganda (100 cases of deliberate self-harm, 300 controls) there was no significant association between religious affiliation and deliberate self-harm. (Kinyanda, Hjelmeland, & Musisi, 2004). group (11% versus 20%, OR 1.95, CI 1.07– Another important dimension is 3.58) (Kralovec, Fartacek, Fartacek, & Plo¨- whether a person’s religious affiliation is derl, 2012).Carlietal.reviewed2,631suicide congruent with his or her local community. attempts in Europe and found that profes- A Scottish longitudinal study (n ¼ 1,698 sing no religion increased the risk of having students, surveyed at ages 11, 15, and 19) a serious suicide attempt (clear intentionality, found higher suicide attempt rates at high case-fatality method, or serious injury), Catholic schools compared to non- as opposed to a non-serious suicide attempt denominational schools, and determined (B ¼ .331, p < .0001) (Carli et al., 2014). this was because of higher rates among Importantly, religious affiliation is not Non-Catholics attending Catholic school protective in all samples. Sisask et al. collected (14.5% attempted suicide) compared to data from seven countries and found that in Catholics attending Catholic school (5.8% South Africa, suicide attempters were more attempted suicide, bivariate p ¼ .016) likely than controls to report a religious affili- (Young, Sweeting, & Ellaway, 2011). ation (n ¼ 541 of 565 suicide attempters versus Whether religious affiliation fosters a sense 414 of 497 controls) (Sisask et al., 2010). The of belonging, or makes a person feel ostra- South African sample was unusual though, cized likely impacts suicide attempt risk. since it had much higher numbers in the ‘‘other religious affiliation’’ category (n ¼ 481 of 1,062) than samples from other countries. Religious Affiliation and Suicide This suggests the common religious affiliation categories did not successfully categorize large The belief that suicide rates vary by numbers of participants, creating the possi- religious affiliation dates back to Emil bility that the result is driven by unmeasured Durkheim, who observed in 1897 that characteristics (unmeasured religious affilia- Protestant states in Western Europe had tions, for instance). The finding should be higher suicide rates than Catholic states, a interpreted cautiously until more detailed data finding he attributed to Protestantism are available. ‘‘being a less strongly integrated church

ARCHIVES OF SUICIDE RESEARCH 7 Religion and Suicide Risk than the Catholic church’’ page 159 a minority group in (atheist) China, which (Durkheim, 1897=2010). puts them at numerical and political disad- Some contemporary data on suicide vantage, and creates strain with mainstream exist from post-mortem record reviews culture. and proxy interviews. In Switzerland, Spoerri et al. used census data (3.7 million Comment adults) and death certificates (5,082 suicides), and found that crude suicide rates We did not find clear evidence that were highest among those with no religious religious affiliation protects against suicidal affiliation (39.0 per 100,000, HR 1.37, CI ideation. However there is evidence that it 1.27–1.48), followed by Protestants (28.5 protects against suicide attempt, and the per 100,000; referent), and Catholics (19.7 severity of suicide attempts. Importantly, per 100,000; HR 0.69, CI 0.65–0.74). protective effects are not seen in every Follow-up analysis accounting for age sug- sample. Before assuming religious affili- gested that, compared to Protestants, the ation is protective, one must consider the protective effect of Catholicism was stron- culture-specific implications of affiliating ger in older persons, and the hazard asso- with a particular religion. In some places ciated with being unaffiliated became the affiliation might connect the person stronger in older persons (Spoerri, with community resources, while elsewhere Zwahlen, Bopp, Gutzwiller, & Egger, the affiliation could isolate the person. 2010). The protective effect of Catholic The religious affiliation variable has or Protestant affiliation was also stronger inherent limitations, which may partially if the person carried a cancer diagnosis, explain why suicide risk is not uniform and weaker when a mental illness (any across all affiliations and all studies ICD-10 F code) was present (Panczak (Table 3). Even within a single affiliation, et al., 2013). The findings raise questions beliefs and practices can vary widely. For about whether religious communities offer instance, the Jewish community includes different support to persons suffering from secular, Reform, Conservative, and cancer, than to persons suffering from Orthodox communities. Moreover indivi- mental illness; whether persons with mental duals may not embrace all of their religion’s illness have more difficulty integrating into teachings, yet remain affiliated with that religious community; or whether mental religion (e.g., many Catholics use contra- illness overwhelms the effects of protective ceptives). The variable also does not factors. account for the social context in which a Researchers in China found the person professes a particular religious affili- opposite trend. When they compared 392 ation, and whether the local society or suicides with 416 controls, they found that government is favorably disposed or hostile suicides were more likely to have a religious to that religious group. While religion affiliation (29.27%) than controls (16.99%, seems to be related to suicide risk, simple multivariable OR 2.906, CI 1.661–5.083) affiliation variables may not capture the ( Jia & Zhang, 2012) see also (Zhang, Wiec- most important distinctions. zorek Conwell, & Tu, 2011). The authors suggest three possible explanations: religion in China has more emphasis on private ATTENDANCE AT RELIGIOUS SERVICES worship which offers less social support AND SUICIDAL BEHAVIOR to believers; Buddhist ideas about reincar- nation may encourage suicide in some Studies consistently report a protective cases; and Chinese religious believers are relationship between religious service

8 VOLUME 20 NUMBER 1 2016 R. E. Lawrence et al. attendance and suicide risk (Table 4), but depression risk, substance use, and social few of these studies adjusted for social sup- support (measured as perceived trust- port as a potential confounder. (Service worthiness of people at school) were added attendance might create opportunities for to the model (OR 1.3, CI .8-2.2) (Rasic, social support, which might reduce suicide Kisely, & Langille, 2011). The study is risk factors.) We focus here on those stu- notable for its high response rate (92%) dies that adjusted for social support, to dis- and a moderately large sample size, but cern whether religious service attendance includes just three high schools in the same offers additional benefits. region. Moreover, religious attendance among adolescents may reflect family norms rather than personal choice. Religious Attendance and Suicidal Ideation A United States study of young adults (n ¼ 454 undergraduate psychology students Perhaps the strongest evidence for at one university) also found that attendance religious service attendance protecting at services predicted less suicidal ideation against suicidal ideation comes from a sam- (t(387) ¼2.44, p ¼ .02), but this associ- ple of 248 depressed older adults receiving ation was not significant when social sup- psychiatric services in the United States port was added to the model (mediational (Rushing, Corsentino, Hames, Sachs- analysis, t(386) ¼ .33, p ¼ .74) (Robins & Ericsson, & Steffens, 2013). More frequent Fiske, 2009). Importantly, the study did attendance at religious activities (measured not calculate a response rate, so there is no with a 6-point scale ranging from never to way to know whether the sample is rep- more than once a week) was associated with resentative (rates of past-year suicidal idea- decreased current suicidal ideation scores tion [35%] and past-year suicide attempt (standardized beta .201, t ¼ 2.709, [10%] were high, suggesting selection bias). p ¼ .007), and this relationship remained The Canadian Community Health sur- significant when social support was added vey (n ¼ 36,984 adults) is the largest study to the model (mediation analysis, Sobel test, we identified addressing this question. z ¼ 2.068, SE 0.015, p ¼ .039), indicating Religious service attendance (dichotomized social support was a partial mediator, yet at never versus once a year or more) religious attendance still played an inde- decreased past-year suicidal ideation after pendent role. This study has the benefits adjusting for sociodemographic factors of a straightforward design and the use of (OR .64, CI .53–.77), but not when adding standardized scales, but is limited by its social support to the model (OR .68, CI sample size and its single-location design. .45–1.03) (Rasic et al., 2009). The sample Three other studies have ultimately size adds credibility to the finding, but found no association between attendance the dichotomized religion scale limits the and suicidal ideation. In a Canadian survey information conveyed. (n ¼ 1,615 high school students), service Overall, these studies show limited attendance (dichotomized at never or a support for religious service attendance few times per year versus once a month having a protective effect on suicidal idea- or more) was protective only among tion, beyond providing social support. females. Specifically, less frequent attendance was associated with more suicidal ideation in the past year (OR 1.6, CI Religious Attendance and Suicide Attempt 1.0–2.5, p < .05) after adjusting for sociodemographic factors. However this Several studies have found lower rates relationship became non-significant when of suicide attempts among persons who

ARCHIVES OF SUICIDE RESEARCH 9 Religion and Suicide Risk attend religious services, after adjusting for service attendance at baseline (wave 1, social support. In the Canadian Community 1981) was associated with lower odds of Health Survey (n ¼ 36,984 adults) past-year suicide attempt at follow up (wave 3, ‘‘suicidal acts’’ (self-reported suicide 1993–1996). This was significant (OR attempt or trying to take one’s own life) 0.43, CI 0.08–0.77) after adjusting for per- were least common among those who ceived quality of social support, size of attended services weekly (referent), with social network, and other covariates (Rasic, greater odds among those who attended Robinson, Bolton, Bienvenu, & Sareen, monthly (OR 2.10, CI 1.98-2.23), 3-4 times 2011). Limitations of this study include per year (OR 4.27, CI 3.97–4.60), once a being geographically limited to East Balti- year (OR 2.94, CI 2.75–3.14), or never more, and having considerable attrition (OR 1.18, CI 1.10–1.25). This was signifi- between baseline assessment (n ¼ 3,481) cant after adjusting for receiving higher and follow up. levels of tangible social support (OR 1.16, We identified only one study where CI 1.15–1.17, defined as material aid or attendance was not associated with suicide behavioral assistance; other social support attempts after adjusting for social support. subscales were not significant in the final In their survey of 454 undergraduate psy- model) (Blackmore et al., 2008). The chology students in the United States, authors offer as a possible limitation that Robins and Fiske (2009) found that attend- there was no measure of suicidal intent, so ance at religious services was protective some reported attempts might have been against suicide attempts (Wald ¼ 4.78, better classified as non-suicidal self-injury. df ¼ 1, p ¼ .03), but not when social sup- Sisask et al. (2010) analyzed inter- port was added to the model (Wald ¼ 1.18, national data from the WHO SUPRE-MISS 1.18, df ¼ 1, p ¼ .28) (Robins & Fiske, study (n ¼ 2,819 suicide attempters; 2009). Limitations (mentioned above) n ¼ 5,484 controls; from Brazil, Estonia, include no reported response rate, and a India, Islamic Republic of Iran, South potentially non-representative sample. Africa, Sri Lanka, and Vietnam). The analy- These studies are fairly consistent in sis did not adjust for social support directly, reporting that religious service attendance but did adjust for marital status and employ- protects against suicide attempts after ment (as well as education, age, and gender). adjusting for social support. Religious service attendance was associated with lower suicide rates in Brazil (weekly OR .33, monthly OR .25, yearly OR .30), Religious Attendance and Suicides Estonia (monthly OR .23), India (yearly OR .45), Islamic Republic of Iran (weekly One study comes close to the issue of OR .50, monthly OR .53, yearly OR .46), religious service attendance and suicides, and Vietnam (yearly OR .28) compared using religious involvement as the variable with non-attenders (referent). Attendance (arguably a frequency measure, dichoto- was not significantly related to suicide mized as yes=no). When comparing sui- attempts in South Africa or Sri Lanka cides (n ¼ 86) and matched controls (Sisask et al., 2010). A possible limitation (n ¼ 86) in the United States, the absence of this study is that the controls were ran- of religious involvement was a risk factor domly selected, and it is unclear how closely for suicide (OR 3.08, CI 1.03–10.79) after they matched the cases. adjusting for social interaction, employ- Longitudinal data from the Baltimore ment, and affective disorder. The study is Epidemiological Catchment Area study limited by not describing its religious vari- (n ¼ 1,015) suggested that more frequent able in detail (Duberstein et al., 2004).

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Comment and I consider suicide morally wrong) have been shown to have less suicidal ideation While religious service attendance is and fewer suicide attempts (Dervic et al., consistently associated with lower suicide 2004; Dervic, Grunebaum, Burke, John risk, much of the effect can be attributed Mann, & Oquendo, 2006; Lizardi et al., to social support rather than religion 2008). Some evidence suggests Moral and specifically. Studies that adjust for social Religious Objections to Suicide are more support generally have not shown service important predictors of suicidal ideation attendance to be protective against suicidal (Dervic et al., 2004) and suicide attempt than ideation. However, multiple studies have religious affiliation (Dervic et al., 2004; shown that service attendance is protective Dervic et al., 2006; Dervic et al., 2011; against suicide attempt. Lizardi et al., 2008). Religious prohibitions The studies face several obstacles: they and fear of divine punishment are prominent rely on self-report and historical recall, sam- themes in qualitative studies from Ghana, ple sizes are often limited, they use different Korea, and Malaysia (Abdul Kadir & social support measures, and persons with Bifulco, 2010; Knizek, Akotia, & Hjelme- the same service attendance frequency land, 2010–2011; Osafo, Hjelmeland, Ako- might differ in other important religious tia, & Knizek, 2011; Jo, An, & Sohn, 2011). characteristics. Additionally, causality can- Qualitative studies suggest religion can not necessarily be inferred: service attend- also be a source of hope (Osafo, Knizek, ance might help a person cope, or might Hjelmeland, & Akotia, 2013). For some, be an indicator that the person is coping this involves feeling reassured of divine and functioning well enough to maintain a control. Undergraduates in Ghana said, social routine. The studies also came pri- ‘‘People who want to commit suici- marily from countries with a significant de ...should know with [God] all the religious presence (mostly Christian), leaving things in this world are possible, and unanswered questions about the role of ser- [God] provides their needs ...’’ (Knizek vice attendance in countries where religious et al., 2010–2011). A United States participation is socially discouraged. veteran—who experienced suicidal Nevertheless, these findings raise the thoughts—commented, ‘‘[God’s] got possibility that religious service attenders something for me to do. And I’m going manage their suicidal ideation differently to find it ...’’ (Brenner, Homaifar et al. than non-attenders, or that the type of sup- 2009). Undergraduates in Ghana found port they receive from the religious com- hope in emphasizing submission to God munity differs from secular social and anticipating a divine reward for support. Neither possibility has been obedience: ‘‘People should be made aware explored in detail. of their existence on earth and who it is that has made them and that this world in which they are in, will one day come to Potential Mechanisms for a an end. This life is not the end of every- Protective Effect thing. There is a better life somewhere therefore, they should take the ultimate Religion might reduce suicide risk way and put their full trust in God, the through shaping a person’s beliefs. Persons maker’’ (Knizek et al., 2010–2011). For who endorse ‘‘Moral and Religious Objec- others, religion offered a meaningful way tions to Suicide’’ (I believe only God has to interpret suffering; faithful perseverance the right to end a life; My religious beliefs (choosing not to commit suicide) could forbid suicide; I am afraid of going to hell; show selflessness, loyalty, and discipline

ARCHIVES OF SUICIDE RESEARCH 11 12 TABLE 4. Quantitative Studies Addressing Associations Between Religious Service Attendance and Suicide Risk

Author/Date Location Sample Suicidal ideation Suicide attempt

(Nonnemaker, United States 16,306 adolescents NS NS McNeely, & Blum, 2003) (Kaslow et al., 2004) United States 100 African-American Less attendance increases risk suicide attempters; 100 controls (Blackmore et al., Canada 36,984 adults Less attendance increases risky 2008) OUE20 VOLUME (Rasic et al., 2009) Canada 36,984 adults More attendance is protectivey More attendance is protectivey (Robins & Fiske, 2009) United States 454 undergraduates More attendance is protectivey More attendance is protectivey (Taliaferro, Rienzo, United States 522 undergraduates More attendance is protective

Morgan Pigg, David UBR1 NUMBER Miller, & Dodd, 2009) (Sisask et al., 2010) Brazil, Estonia, India, Islamic 2,819 suicide attempters; More attendance is protective (not significant

2016 Republic of Iran, South 5,484 controls for South Africa or Sri Lanka)y Africa, Sri Lanka, Vietnam (Rasic et al., 2011) Canada 1,615 high school Less attendance increases risk NS students for females onlyy (Langille, Asbridge, Canada 1,597 high school More attendance is protectivey NS Kisely, & Rasic, students 2012) (Rasic et al., 2011) United States 1,091 adults NS More attendance is protectivey (Chatters et al., 2011) United States 2,870 African-Americans; NS NS 1,256 Black Caribbean-Americans (Taylor et al., 2011) United States 3,570 African-Americans; More attendance is protective More attendance is protective for 1,621 Black for African-Americans; NS African-Americans; frequent attendance Caribbean-Americans for Black increased risk among Black Caribbean-Americans Caribbean-Americans (Robinson, Bolton, United States 2,178 Asians; 3,264 Less attendance increases risk Less attendance increases risk for Hispanics Rasic, & Sareen, Hispanics; 5,825 for Hispanics and Whites 2012) African-Americans; 5,071 Whites

RHVSO UCD RESEARCH SUICIDE OF ARCHIVES (Langille, Asbridge, Canada 1,597 high school More attendance is protective NS Kisely, & Rasic, students 2012) (Nkansah-Amankra et United States 9,412 adolescents More attendance is protectivey NS al., 2012) (Hoffman & Marsiglia, Mexico 702 high school students More attendance is protective 2012) (Caribe et al., 2012) Brazil 110 attempters, 114 More attendance is protective controls (Rushing et al., 2013) United States 248 depressed older More attendance is protectivey NS adults receiving psych services (Stroppa & Brazil 168 bipolar outpatients NS Moreira-Almeida, 2013) (Stratta et al., 2012) Italy 426 adults exposed to an NSz earthquake, 522 controls

Not significant after adjusting for covariates. yThe analysis adjusted for social support. zAuthors combined suicidal ideation and attempt. 13 Religion and Suicide Risk

TABLE 5. Qualitative Studies Addressing Religion and Suicide, Published 2003–2013

Authors, Date Country Participants

(Mohr et al., 2006) Switzerland 118 adults with schizophrenia (Huguelet et al., 2007) Switzerland 115 adults with schizophrenia, and 30 non-psychotic inpatients with prior suicide attempt (Alexander et al., 2009) United States 198 adults with mental illness and a prior suicide attempt (Brenner, Homaifar, Adler, Wolfman, & United States 13 veterans with traumatic brain injury Kemp, 2009) and suicidal ideation=behavior (Abdul Kadir & Bifulco, 2010) Malaysia 61 women with depression (Knizek et al., 2010–2011) Ghana 196 psychology undergraduates (Osafo et al., 2011) Ghana 15 psychology undergraduates (Yodchai, Dunning, Hutchinson, Thailand 5 adults receiving hemodialysis Oumtanee, & Savage, 2011) (Jo et al., 2011) Korea 134 undergraduates with suicidal ideation but no attempt (Mason et al., 2011) United States 15 Protestant clergy (Oliffe et al., 2012) Canada 38 men with depression (Bullock et al., 2012) Canada 15 adolescent suicide attempters (Osafo et al., 2013) Ghana 27 adults in the community

(Oliffe, Ogrodniczuk, Bottorff, Johnson, & findings have not yet been studied Hoyak, 2012). quantitatively. Qualitative literature has also identified prayer as an important tool for managing suicidal thoughts (Osafo et al., 2013). RELIGION AS A RISK-FACTOR Undergraduates in Ghana reported, FOR SUICIDE ‘‘Whatever problems we have, we can just go on our knees and pray, and it’s going An important yet under-studied area is why to be solved’’ (Osafo et al., 2011). How- religion is sometimes associated with ever, this has not been observed so clearly increased suicide risk. A few studies have in quantitative studies (see supplementary identified patterns of ‘‘negative religious materials). coping,’’ which may include: deferring all These data suggest a variety of ways responsibility to God, feeling abandoned that religious individuals might manage by God, blaming God for difficulties, their suicidal thoughts, but do not suggest experiencing spiritual tension or doubt, or that religious persons will have fewer suici- experiencing conflict and struggle with dal thoughts. This is consistent with our God (Pargament, Smith, Koenig, & Perez, initial hypothesis that religion will protect 1998). We found two studies in which against suicide attempts but not necessarily negative religious coping increased suicide against suicidal ideation. The data are lim- risk. One study involved Croatian war ited; they represent a small number of stu- veterans (n ¼ 111 veterans with post- dies which include non-clinical populations traumatic stress disorder; 39 controls), (Table 5), and many of the qualitative and the other study involved earthquake

14 VOLUME 20 NUMBER 1 2016 R. E. Lawrence et al. victims in Italy (n ¼ 426 victims and 522 might be a marker for emotional distress, controls; [Mihaljevic, Aukst-Margetic et al., rather than a simple protective factor. 2012; Stratta et al., 2012]). Both studies are Qualitative studies shed further light geographically limited, utilize a case-control on moments where religion can be a risk design, and do not distinguish between sui- factor. Swiss patients with schizophrenia cidal ideation and attempts. Additionally, or depression mentioned: wishing to die the focus on trauma victims might not rep- and be with God, wishing to live another resent attitudes from other populations. life after death, feeling angry with God, los- Nevertheless, the results suggest this is an ing faith, losing meaning in life, breaking important area for further study, and may with their religious communities, or feeling suggest a special area of inquiry for trauma unsupported by their religious communities research. (Huguelet et al., 2007; Mohr, Brandt, There are other studies where high Borras, Gillie´ron, & Huguelet, 2006). levels of religious activity are occasionally associated with more suicide risk. Prayer was a risk factor for suicidal ideation in a CONCLUSION longitudinal study of adolescents in the United States (n ¼ 9,412); compared to Our review of the literature yields several those who pray once a week, those who important conclusions. Many studies indi- never pray were at reduced risk of suicidal cate religious affiliation is protective ideation (OR 0.34, CI 0.13-0.89) against suicide attempts and suicide, but (Nkansah-Amankra et al., 2012). Similarly, not suicidal ideation. Likewise attendance among Black-Caribbeans in the United at religious services is protective against States (n ¼ 1,621), respondents who said suicide attempt, but not suicidal ideation prayer is important during stressful situa- (after adjusting for social support). These tions were more likely to report suicidal studies suggest religion may inhibit a per- ideation (OR 2.80, CI 1.38–5.71 [Taylor, son from acting on suicidal ideas by: pro- Chatters, & Joe, 2011]). Reading religious viding access to a supportive community, material was also associated with suicidal shaping a person’s beliefs about suicide, ideation in a study of African-Americans providing a source of hope, providing ways in the United States (n ¼ 3,570, OR 1.24, to interpret suffering. CI 1.11–1.38; [Taylor et al., 2011]). In The literature also indicates that the another analysis of African-American relationship between religion and suicide respondents (n ¼ 2,870) and Black- risk is complex. Different religious affilia- Caribbeans (n ¼ 1,256), more frequent tions provide different degrees of protec- interaction with members of one’s religious tion. Religious affiliation can connect a community was associated with greater person to community, but adhering to a likelihood of a lifetime suicide attempt minority affiliation might also cause feel- (OR 1.14, CI 1.02–1.27) (Chatters, Taylor, ings of isolation. In countries or societies Lincoln, Nguyen, & Joe, 2011). These stu- that oppose specific religions or religion-in- dies should be interpreted cautiously, for general, a person’s religious beliefs and they are scattered amidst numerous other practices are less likely to protect against studies showing religious activity to be suicide. If religion leaves a person feeling protective, and could represent type 1 guilty, distant from God, or abandoned error. However they do raise the possibility by the religious community, that can of a subgroup of persons who increase increase suicide risk. their religious activity in response to Existing studies have limitations. distress. For this group, religious activity Religious variables often lack detail, which

ARCHIVES OF SUICIDE RESEARCH 15 Religion and Suicide Risk makes it difficult to identify the most active A particularly important area to components of the relationship between address in future study involves the timing religion and suicide risk. The religious vari- of suicide risk and religious characteristics. ables considered here address very different Both suicide risk and some religious char- aspects of religion (e.g., affiliation versus acteristics (e.g., feeling close to God) can practices) which limit attempts to general- change over time, and researchers have ize conclusions to religion in general. The yet to ask participants ‘‘In the moment existing studies are thinly spread across when you were acutely suicidal, what was many locations, cultures, age groups, and the role of religion?’’ Another research diagnostic groups; limiting efforts to draw area, also related to timing, would be to general conclusions about the role of religi- examine how the experience of physical on in general for specific groups (e.g., its or mental illness might shape a person’s role among adolescents, or among cancer religious characteristics. It would also be patients). Most of the quantitative studies valuable to understand how society’s view use a cross-sectional design, allowing of the individual’s religious characteristics researchers to identify correlations without impacts suicide risk since there are some necessarily identifying causal direction. communities where religious participation Religious or spiritual practices may be can increase a person’s connection to especially difficult for persons who are society, and other communities where hopeless, depressed, and suicidal; suggest- particular forms of religion can increase ing they could serve as markers of feelings of isolation. emotional well-being and social functioning Ideally, research findings on the role of rather than independent protective factors. religion could help generate educational Additionally, studies involving special interventions so that clinicians can help populations (e.g., persons with physical or religious patients access religious supports, mental health diagnoses) may not be and so that religious communities (and directly comparable to studies among the their leaders) can increase their awareness general population if those special popula- of what they are doing that is helpful and tions have different experiences of religion provide more of it. or community involvement. Moreover this systematic literature review has limitations. We used a single AUTHOR NOTE database, utilizing four sets of search terms, which may not have captured all relevant Ryan E. Lawrence, Department of articles. The large number of articles Psychiatry, Columbia University Medical reviewed here does not allow in-depth dis- Center, New York, NY. cussion of many important articles. Maria A. Oquendo, Department of Many future research directions are Psychiatry, Columbia University Medical possible. Existing studies address similar Center and the New York State Psychiatric questions, and use similar measures, which Institute, New York, NY. might lend themselves to meta-analysis. Barbara Stanley, Department of Studies could also examine whether there Psychiatry, Columbia University Medical are identifiable sub-populations that are Center and the New York State Psychiatric especially helped by religion, and others Institute, New York, NY. for whom religion is unhelpful. Qualitative Correspondence concerning this article studies might ask participants about their should be addressed to Ryan Lawrence religious involvement specifically during MD, MDiv. Department of Psychiatry, periods of suicidal ideation. Columbia University Medical Center, New

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