Veganism, animal rights, and suicide prevention

Update: A message from Tedros Adhanom Ghebreyesus (51 sec)

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“The one who dares to think, however, who queries existence, who tries to grasp the meaning of the life that he carries, who witnesses the suffering of the world, … he knows the hours in which the horror of existence is stronger to him than the horror of not existing anymore […].” Albert Schweitzer (Brüllmann and Gräßer 2001)

“Suicide is a potentially preventable public health issue.” (Sampasa-Kanyinga et al. 2017)

“The prevention of suicide has not been adequately addressed due to a lack of awareness of suicide as a major public health problem and the taboo in many societies to openly discuss it.” (WHO 2018)

Note: This post does not address the question of whether suicide can be “morally wrong” or “morally right”. It does not discuss “rational suicide” (Mayo 1986). Neither does it address wacky fundamentalist ideas like suicide being a “sin” or suicide in the form of harakiri/seppuku/jigai (Maiese et al. 2014; Koseki 1990) as an “honourable” way of ending one’s life.

The Belvedere Torso (the Vatican Museum) – might depict Ajax (who in Greek mythology committed suicide)



Background
Global statistics:
- Close to 800 000 people die due to suicide every year (WHO 2018) – that means that, statistically speaking, every 40 seconds someone dies by suicide.

- Suicide is the second leading cause of death among 15 to 29-year-olds (WHO 2018). [The first is accidents.]

- Around 80% of global suicides occur in low- and middle-income countries (WHO 2018).



Suicide is common
Suicidal thoughts are common. Suicide attempts as well as suicides are also quite common.

Ajax (Glyptothek Munich)

- A study from China with 12,733 children and adolescents aged 9 to 18 years (from many a wide range of areas across China showed that about 32% reported suicidal thoughts (38% in females, 30% in males) (Tan et al. 2018).

- A study from Canada (Ottawa) with 1,922 students aged 11 to 20 years (2009, 2011 and 2013) found that about 11% reported having suicidal thoughts and 3% reported suicide attempts within the past 12 months. The probability of making a suicide attempt if there were suicidal thoughts, was estimated to be about 26% (Sampasa-Kanyinga et al. 2017).

- A study from European countries with 11,110 students, 14 to 16 years old (in 11 European countries: Austria, Estonia, France, Germany, Hungary, Ireland, Italy, Romania, Slovenia, Spain, and Sweden) showed that about 11% had depression, about 6% had anxiety, about 28% reported “deliberate self-injurious behaviours” at some point within their lifetime. About 32% reported suicidal thoughts, and about 4% (5% of girls and 3% of boys) reported suicide attempts at some point in their lifetime (Wasserman 2016).

- Two studies from Vietnam with 4,609 and 6,508 adolescents aged 14 to 19 years (2003–2004 and 2009–2010) found that about 34% and 37% reported “experiences of low mood” and about 5% and 12% reported “suicidal behaviors” (Le et al. 2012).

- In the United States each year, nearly half a million individuals present to the emergency rooms following attempted suicide. Nearly 1 out of every 7 young adults [i.e. about 14%] describe having had suicidal thoughts at some point in their lives and at least 5% have made a suicide attempt. In the US men are more than three times more likely than women to commit suicide, and on average 123 people kill themselves every day. “Suicides are at an all-time high […]” (Bhimji and Dulebohn 2018).

CDC 2019 (CDC 2019)


CDC 2019, United States data (CDC 2019)



Methods of committing suicide
Most common methods:
- self-poisoning with pesticides – around 20% of global suicides, mostly in rural agricultural areas in low-
and middle-income countries (WHO 2018; Gunnell et al. 2017)
- hanging (WHO 2018)
- firearms (WHO 2018)

Other methods:
- self-immolation (self-burning, setting oneself on fire) (Wu et al. 2012)
Self-immolation suicide is relatively common in Iran. One study found: “Self-immolation […] is the most tragic and violent method of suicide. The higher prevalence of this dramatic phenomenon in Iran is a serious social and health problem. […] individuals who attempted self-immolation in Iran were mainly women [70%], married [61%] and young adults [95% between 25 and 29 years old].” (Parvareh et al. 2018) Another study from Iran found that 83% of self-immolation suicide attempters were women (Moradinazar et al. 2016).
In the Buddhist context suicide by self-immolation has been quite widely documented, especially as a form of political protest, for example in Vietnam (Kelly 2011), South Korea (Ben Park 2004) China and Tibet (Zarghami 2012).
Self-immolation suicide as a form of political protest has also been committed by Falun Gong practitioners in China (Zarghami 2012).
Self-immolation suicide has been documented in many other countries, for example in India, Tunisia, Algeria, Egypt, Saudi Arabia, Mauritania, Syria, Ethiopia, the United States, the Czech Republic, and Germany – as a form of political protest, for religious reasons (Zarghami 2012), because of personal life circumstances (such as separation from one’s life partner, or financial problems) (Romm et al. 2008; Rothschild et al. 2001; Lévy et al. 2017), or due to psychosis (Rothschild et al. 2001). (In the context of psychosis self-immolation has also been documented without suicidal intention (Niethammer and Breitmaier 2005).)
- self-poisoning with poisonous plants (Wu et al. 2012)
- jumping to one’s death (Wu et al. 2012)

“Common suicide methods shift with the introduction of technologies and constructions, and have specific age- or sex-characteristics […].” (Wu et al. 2012)



Warning signs
“By far the strongest risk factor for suicide is a previous suicide attempt.” (WHO 2018)

Red flags:
- prior suicide attempt (WHO 2018; Oexle and Rüsch 2018)
- suicidal thoughts (Sampasa-Kanyinga et al. 2017) (Questions: Have you considered committing suicide? Have you thought about how you would do it? If this last question is answered with “yes”, the risk is very high.)

“For every suicide there are many more people who attempt suicide every year.” (WHO 2018)



Risk factors
“[M]any suicides happen impulsively in moments of crisis with a breakdown in the ability to deal with life stresses, such as financial problems, relationship break-up or chronic pain and illness.” (WHO 2018)

Risk factors for committing suicide (in no particular order of importance):
MENTAL HEALTH PROBLEMS
- psychotic illness/hallucinations (Wasserman 2016; Goldblatt et al. 2016)
“Suicides of patients in states of acute persecutory panic may be provoked by a subjective experience of helpless terror threatening imminent annihilation or dismemberment. These patients are literally scared to death and try to run away. They imagine suicide is survivable and desperately attempt to escape from imaginary enemies. These states of terror occur in a wide range of psychotic illnesses and are often associated with command hallucinations and delusions.” (Goldblatt et al. 2016)
- depression (especially in high-income countries) (WHO 2018; Wasserman 2016; Bhimji and Dulebohn 2018)
- anxiety (Tan et al. 2018; Wasserman 2016; Bhimji and Dulebohn 2018)
- bipolar disorder (Johnson et al. 2017; Latalova et al. 2014; Costa et al. 2015)
“It is estimated that 25% to 50% of patients with bipolar disorder will attempt suicide at least once over their lifetime, and that 8% to 19% will complete suicide.” (Latalova et al. 2014)
“Bipolar disorder [..] is a severe psychiatric illness that has been ranked as one of the 20 leading medical causes of disability […]. [Bipolar disorder] has been shown to be the psychiatric disorder with the highest rates of completed suicide across two major cohort studies […].” (Lima et al. 2018)
- post-traumatic stress disorder or neurosis (Bhimji and Dulebohn 2018)
- anorexia nervosa and other eating disorders (Thornton et al. 2016; Lian et al. 2017)
“[…] one-quarter to one-third of people with AN [anorexia nervosa] and BN [bulimia nervosa] have attempted suicide. […] individuals with AN are 18 times more likely to die by suicide, and individuals with BN are seven times more likely to die by suicide.” (Smith et al. 2018)
- mental illness in general (Bhimji and Dulebohn 2018) and the stigmatization of mental illness (Oexle and Rüsch 2018)
- psychological stress (Bhimji and Dulebohn 2018)
PHYSICAL HEALTH PROBLEMS
- alcohol addiction (especially in high-income countries) (WHO 2018)
- certain medications (Bhimji and Dulebohn 2018)
- physical illness that has led to disability (Bhimji and Dulebohn 2018)
- chronic pain/chronic illness in general (WHO 2018; Bhimji and Dulebohn 2018)
- chronic sleep disorders (Bhimji and Dulebohn 2018) or lack of sufficient good sleep (Wasserman 2016)
- traumatic brain injury (in military personnel) (Bhimji and Dulebohn 2018)
ABUSE FROM OTHERS
- experiencing discrimination (WHO 2018)
- experiencing personal conflict (WHO 2018)
- experiencing bullying (Sampasa-Kanyinga et al. 2017) (possibly especially “relational bullying” such as
social exclusion or the spreading of negative rumours (Wasserman 2016)
- experiencing violence/abuse in general (in the past or currently) (WHO 2018; Le et al. 2012; Bhimji and Dulebohn 2018) (especially also sexual abuse in childhood (Ng et al. 2018))
FEELINGS/SELF-PERCEPTION
- hopelessness (Oexle and Rüsch 2018)
- perceived social failure (Chen et al. 2017)
- shame (Chen et al. 2017)
- a sense of no purpose in life (Bhimji and Dulebohn 2018)
- low self-esteem (Oexle and Rüsch 2018)
- self-blame (Tan et al. 2018)
- concerns about own sexual orientation (Wasserman 2016)
LIFE CIRCUMSTANCES
- imprisonment (WHO 2018)(WHO 2018; Cramer et al. 2017)
- financial difficulties (WHO 2018; Bhimji and Dulebohn 2018; Wu et al. 2012)
- unemployment/very low income/loss of job (Bhimji and Dulebohn 2018)
- a cultural background that accepts certain forms of suicide (Wu et al. 2012)
- having no religion (or a religion that endorses certain forms of suicide) (Wu et al. 2012)
- (possibly) Caucasian ethnicity (Bhimji and Dulebohn 2018)
- migration background (being a “foreigner” or being perceived as “foreign”) (Wasserman 2016)
- female gender (regional differences: often higher risk in females but sometimes – for example in the
United States – higher risk in males) (Bhimji and Dulebohn 2018)
- early age of first sexual intercourse (Gambadauro et al. 2018)
- divorce (Bhimji and Dulebohn 2018)
- relationship break-up (WHO 2018)
- loss of a relative by suicide (family history of suicide) (Bhimji and Dulebohn 2018; Oexle and Rüsch 2018) or other exposure to suicide (for example a friend committing suicide) (Jordan 2017)
- advanced age (Bhimji and Dulebohn 2018)
- loss of a loved one (for example one’s life partner) or traumatic life events in general (WHO 2018) (Bhimji and Dulebohn 2018)
- social isolation (WHO 2018; Bhimji and Dulebohn 2018; Oexle and Rüsch 2018)
- excessive work load (for example in school) (Le et al. 2012)
- divorce of parents (Tan et al. 2018)
- dysfunctional family (Le et al. 2012)
- (possibly) living in a wealthier family (Tan et al. 2018; Le et al. 2012)
- belonging to a minority (for example an ethnic minority) (Le et al. 2012)
- being illiterate (Le et al. 2012)
- negative life experiences in general (Bhimji and Dulebohn 2018)
- availability of a firearm or other “lethal means” that could be used to commit suicide (Bhimji and Dulebohn 2018)
BEHAVIOUR PATTERNS
- impulsivity (Tan et al. 2018)
- self-harm behaviours (excessive alcohol, smoking, drugs, intentional self-inflicted damage to the
surface of one’s body, for example by self-cutting, self-burning, self-hitting, self-biting, etc.) (Sampasa-Kanyinga et al. 2017; Wasserman 2016; Borges et al. 2017; King et al. 2018)
- pathological internet use (Wasserman 2016; Bhimji and Dulebohn 2018).

“[H]aving just one risk factor has very limited predictive value. [Many people] have one of these factors at any one point in time, but very few attempt suicide and even fewer die as a result. One has to look at the entire clinical picture to increase the predictive values of these risk factors.” (Bhimji and Dulebohn 2018)



The problem of stigmatization
“Both mental illness and suicide are stigmatized, which […] potentially contributes to suicidality among stigmatized individuals.” (Oexle and Rüsch 2018)

- Many people are stigmatized for many different reasons (including stigmatization because of sexual preferences, ethnicity, personal beliefs, mental illness (Picone 2012), etc.).
- Discussing suicide, committing suicide, and/or having a family member who committed or attempted suicide are all stigmatized (Chen et al. 2017; Picone 2012).

Ajax

Consequences of stigmatization:
- Stigmatization can lead to suicide: “Many consequences of stigma, e. g. social isolation, low self-esteem
and hopelessness, are well-known predictors of suicidality.” (Oexle and Rüsch 2018)
- Stigmatization can prevent people with suicidal thoughts from getting help: “Stigma, particularly
surrounding mental disorders and suicide, means many people thinking of taking their own life or who have attempted suicide are not seeking help and are therefore not getting the help they need.” (WHO 2018) Stigmatization of suicide can also prevent “suicide loss survivors” (family members and friends of people who have committed suicide) to seek professional help such as psychological counselling.



Potentially protective factors

Potentially protective factors against suicide:
- a sense of community/belonging (Sampasa-Kanyinga et al. 2017)
- religion (Lizardi and Gearing 2010; Jung et al. 2017; Gearing and Alonzo 2018) – maybe because of community support/community participation (Fang et al. 2011), a trust in the “divine”, a feeling of safety (life after death, god as a protector with a bigger plan, a feeling of having a purpose in life, etc.)
“Research has repeatedly demonstrated that religiosity can potentially serve as a protective factor against suicidal behavior.” (Lizardi and Gearing 2010)
“For an overwhelming majority of commentators, including many anthropologists, 'Japanese culture' is still associated with a positive view of suicide. Western-language writings have contributed by feedback loop to perpetuate this stereotype. Besides the local 'samurai ethic', Japanese Buddhism is also said not to prohibit taking one's life. However, the most popular examples of heroic self-sacrifice, from the Edo period to WWII, are fraught with covert contradictions. From ancient times to the present religious practitioners of all sorts have maintained that suicide creates unhappy, resentful spirits who harm the living.” (Picone 2012)
A belief in reincarnation: “Therefore, human beings cannot avoid suffering by taking their own lives, nor do they escape from “the wheel of suffering” by doing so. Moreover, the consequence of suicide is a rebirth in the woeful planes of existence, and hence further suffering endlessly.” (Disayavanish and Disayavanish 2007)
“The act of suicide is condemned across major religions. In addition, each major religion
provides a series of effective coping strategies (e.g., prayer, rituals, religious services, social networks) to support an individual managing difficulties, such as [suicidal thoughts and considering] suicide. Research over the last decade has expanded our understanding of the complicated relationship between religiosity and suicidality. While it is now generally accepted that religion most often serves as a protective factor against suicide across religious denominations, there are aspects of religion that are now recognized as potentially representing a risk factor for increased suicide risk for some followers.” (Gearing and Alonzo 2018)



Suicide prevention
Ajax …

… and what could have happened

“Suicide […] rates have increased despite more funding and broader implementation of youth suicide-prevention programs.” (Musci et al. 2018)

“As rates of suicide continue to rise, there is urgent need for innovative approaches to better understand, predict, and care for those at high risk of suicide.” (Torous et al. 2018)

“The climbing youth suicide rate warrants an urgent, concerted effort to develop and implement effective prevention strategies.” (King et al. 2018)

“[…] suicides are preventable with timely, evidence-based and often low-cost interventions.” (WHO 2018)

Suicide prevention at the national and international level
Like diabetes, cardiovascular disease and cancer, suicide is a major public health problem, affecting millions of people.
- Suicide prevention strategies need to enter public policies of national governments. Campaigns need to
include creating awareness of the problem, destigmatization and de-taboo-ization of suicide, and programmes targeting high-risk individuals (WHO 2018).
- Suicide prevention campaigns/programmes need to be implemented by governments, religious
communities, non-governmental organizations (NGOs), health insurance companies, other big companies, sports clubs, youth clubs, etc.
- Current sustainability debates include various dimensions such as environmental protection, economic
aspects, and health – under the health umbrella they should include suicide prevention.
“[…] the suicide mortality rate is an indicator of target 3.4 of the Sustainable Development Goals: by 2030, to reduce by one third premature mortality from noncommunicable diseases through prevention and treatment, and promote mental health and well-being.” (WHO 2018)
“To date, only a few countries have included suicide prevention among their health priorities and only 38 countries report having a national suicide prevention strategy.” (WHO 2018)
“[…] implications for the prevention of suicide [:] […] both contextual (city-level) and compositional (individual-level) factors could be important targets for prevention and intervention for children and adolescents at risk of suicide ideation.” (Tan et al. 2018)
Note: In the scientific literature suicidal thoughts are often referred to as “suicidal ideation”.

Strategies/ideas:
- “alcohol policies to reduce the harmful use of alcohol” (WHO 2018; Xuan et al. 2016) (such as alcohol
pricing and taxation, minimum legal drinking age, and outlet density (Xuan et al. 2016))
- “National bans on highly hazardous pesticides, which are commonly ingested in acts of self-poisoning,
seem to be effective in reducing pesticide-specific and overall suicide rates. Evidence is less consistent for sales restrictions. A worldwide ban on the use of highly hazardous pesticides is likely to prevent tens of thousands of deaths every year.” (Gunnell et al. 2017)
- gun control (reducing availability of guns) (Mann and Michel 2016; Rodríguez Andrés and Hempstead 2011)
- suicide barriers on bridges (Sinyor et al. 2017; The Lancet 2017)

“Preventing suicide by restricting access to suicide methods is one of the few evidence-based suicide prevention strategies.” (Wu et al. 2012)

Suicide prevention at the community level
“The weightiest concern about suicidal behavior is how difficult it is for healthcare professionals to predict.” (Berardis et al. 2018)

“Suicide rates were reduced in six of eight observational studies of population-level interventions.” (Nelson et al. 2017)

Strategies/ideas:
COMMUNITY
- community campaigns for more suicide awareness and for destigmatization of suicide
“Raising community awareness and breaking down the taboo is important for countries to make progress in preventing suicide.” (WHO 2018)
“In many Western countries, the criminalization and stigmatization of suicide has given way to a biomedical approach aimed at destigmatizing suicide and treating underlying mental illness. By contrast, in many East Asian countries, suicide has never historically been criminalized or stigmatized. High rates of suicide in Japan, South Korea, and Taiwan have recently led policy makers in those countries to pursue innovative suicide-prevention strategies. The intentional denormalization of harmful behaviors has been discussed […] particularly with regard to smoking cessation, and could represent a novel mechanism for preventing suicides in East Asia. […] care must be taken to avoid shaming or stigmatizing suicidal individuals. […] Given the severe stigma of mental illness in East Asia, adopting the dominant Western view of suicide as solely a psychiatric concern would not be justified [at least not in East Asia]. Weak denormalization strategies in East Asia should […] include social support[.], praise for the bravery of those [..] who seek help, and strategies to reduce shame regarding perceived social failure.” (Chen et al. 2017)
- community programmes to address risk factors, including mental health issues, discrimination,
stigmatization, bullying and smoking (Wasserman 2016)
“A comprehensive public health strategy for adolescent suicide prevention includes […] strategies for risk recognition, and services for those at risk. Interpersonal trauma and substance use are important prevention targets as each is associated with risk for suicide attempts. […] the Family Check-Up, designed to reduce substance use and behavioral problems, also has been associated with reduced suicide risk.” (King et al. 2018)
- community programmes in schools, universities, companies, and in other community settings, and
conducted and instigated by government bodies, academic work groups, NGOs, companies, etc.
“[…] the intervention empowering pupils, called the Youth Aware of Mental Health (YAM) showed significant results in preventing new cases of suicide attempts, severe suicidal ideation with plans and depression. More than a 50% reduction of incident cases of suicide attempts […] was observed. […]
The YAM intervention is designed to promote knowledge about mental health, healthy lifestyles and behaviours among adolescents. All pupils in the classrooms are provided with a customized educational, awareness-raising booklet covering six spe¬cific topics concerning: (1) awareness of mental health and health/risk behaviours; (2) self-help advice; (3) stress and crisis; (4) depression and suicidal thoughts; (5) helping a troubled friend; and (6) getting advice – who to contact. The booklet also includes telephone numbers and email addresses to local healthcare facilities and healthy lifestyle groups in case pupils wish to seek help. Once the intervention commences, six posters are hung in the classroom covering the six key topics as in the awareness booklets. Lessons, which are combined with role-play sessions, address the six topics covered in the awareness booklet and posters […].” (Wasserman 2016)
HEALTH CARE
- training of health workers in suicide risk detection and management of suicidal behaviour (WHO 2018)
“[…] at least 45% of suicide victims in the US have had some contact with a primary health care provider within the 4 weeks before the suicide.” (Bhimji and Dulebohn 2018)
- follow-up care for people who have attempted suicide, linking to community support programmes
(WHO 2018)
- better medical treatments for mental illness, and better diagnostic tools for suicide risk (biomarkers for
suicide risk) (Berardis et al. 2018)
- multidisciplinary support structures for individuals at risk of suicide
- practical tools for assessing risk factors and protective factors (Cramer and Kapusta 2017)
“Risk assessment methods have been shown to be sensitive predictors of suicide and suicide attempts, but the frequency of false positives limits their clinical utility. Research to refine these methods and examine clinical applications is needed.” (Nelson et al. 2017)
- destigmatization of suicide among health care professionals (Oexle and Rüsch 2018)
- practical and helpful tools for those who seek help, for example suicide hotlines
(Shaw and Chiang 2018) (including web chat)
“[Suicide] Hotlines are among commonly available and recommended suicide prevention strategies in many countries […]. This study […] of the Taiwan National Suicide Prevention Hotline [showed] significant decreases in [callers’] emotional distress and suicidality […] during the course of the telephone session. […] The hotline is a useful suicide preventive and crisis intervention service. However, further creative and consistent work is needed to make the service more appealing to the hard-to-reach population.” (Shaw and Chiang 2018)
TECHNOLOGY
- development of multi-level suicide risk algorithms (Cramer and Kapusta 2017)
“Several youth screening instruments have shown utility, and a large-scale trial is underway to develop a computerized adaptive screen.” (King et al. 2018)
“Advances in smartphone sensing, machine learning methods, and mobile apps directed towards reducing suicide offer promising evidence; however, most of these innovative approaches are still nascent. […] Whereas numerous promising mobile and sensor technology based solutions for real time understanding, predicting, and caring for those at highest risk of suicide are being studied today, their clinical utility remains largely unproven. However, given both the rapid pace and vast scale of current research efforts, we expect clinicians will soon see useful and impactful digital tools for this space within the next 2 to 5 years.” (Torous et al. 2018)
“[…] using social media data to detect those at risk for suicide. Specifically, we use natural language processing and machine learning (specifically deep learning) techniques to detect quantifiable signals around suicide attempts, and describe designs for an automated system for estimating suicide risk, usable by those without specialized mental health training (eg, a primary care doctor). […] Currently, this technology is only used for intervention for individuals who have “opted in” for the analysis and intervention, but the technology enables scalable screening for suicide risk, potentially identifying many people who are at risk preventively and prior to any engagement with a health care system. This raises a significant cultural question about the trade-off between privacy and prevention – we have potentially life-saving technology that is currently reaching only a fraction of the possible people at risk because of respect for their privacy. Is the current trade-off between privacy and prevention the right one?” (Coppersmith et al. 2018)
- suicide awareness when developing new suicide-unrelated technologies (Wu et al. 2012)
“In the information society, suicide prevention that focuses on suicide methods must monitor and control the innovation and spread of knowledge and practices of suicide “technologies”. It may be more cost-effective to design safety into technologies as a way of suicide prevention while there is no rash of suicides yet by the new technologies.” (Wu et al. 2012)
MEDIA
- responsible reporting by news media (WHO 2018) (There are WHO Media Guidelines on how to and
how not to publicize suicides (Zarghami 2012)).
“Some people imitate another suicide that they know about either from local knowledge, having a close relationship or from the media. Following Goethe’s novel “Die Leiden des jungen Werthers” (The Sorrows of Young Werther) in 1774– in which many men replicated the act of the hero (shooting himself) [..]. [..] the effect of this knowledge is called “Werther effect” [..]. This process is called “suicide contagion” [..], and this kind of suicide is known as “copycat suicide” […].
[…] widely publicized celebrity suicides are more likely to precipitate a copycat suicide […]. Examples of celebrities whose information had been publicized and disseminated via mass media and have inspired suicide clusters include Ruan Lingyu, the Japanese musicians Yukiko Okada and Hide and Marilyn Monroe, whose suicides was followed by an increase of 200 more suicides than average for one month […].” (Zarghami 2012)

“Suicide is a complex issue and therefore suicide prevention efforts require coordination and collaboration among multiple sectors of society, including the health sector and other sectors such as education, labour, agriculture, business, justice, law, defense, politics, and the media.” (WHO 2018)

Suicide prevention at the individual level

Strategies/ideas:
- talking about suicide with people assumed to be at risk of suicide
“Asking about suicide does not provoke the act of suicide. It often reduces anxiety and helps people feel understood.” (WHO 2018)
- reducing access to the means of suicide in the household (for example, firearms, certain medications,
pesticides, etc.)
- Suicide awareness in individuals from the general public (not just health workers) can save lives.
“[…] early identification, treatment and care of people with mental and substance use disorders, chronic pain and acute emotional distress […].” (WHO 2018)
- “Sending” someone to psychotherapy could be good, but it is not enough.
“Only two of ten trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care […].” (Nelson et al. 2017)



Depression as a risk factor
The potential influence of a healthy diet on depression has been discussed in another article, see here.

The following (non-dietary) factors are associated with an increased risk of depression and/or anxiety:
- lack of physical activity (Wasserman 2016)
“Frequency of physical activity was positively correlated with wellbeing and negatively correlated with both anxiety and depressive symptoms, up to a threshold of moderate frequency of physical activity” (Wasserman 2016)
- lack of sufficient good sleep (Wasserman 2016)
“Reduced sleep was significantly associated with emotional symptoms, conduct problems, anxiety and suicidal ideation.” (Wasserman 2016)
- smoking
“[…] smoking was significantly associated with emotional symptoms, conduct problems, hyperactivity, excessive alcohol and illicit drug use, anxiety and previous suicide attempts [.]. The interaction between psychosocial factors and adolescent smoking are highly correlated with parental behaviours and family structure. The study concluded that the early onset and long-term smoking are associated with both physical and psychological health problems.” Wasserman 2016 (Wasserman 2016)
- harmful internet use: using the internet longer than intended, preoccupation with the internet,
withdrawal symptoms when unable to access the internet, unsuccessful attempts to stop or reduce internet use, internet craving, loss of interest in hobbies or activities outside of the internet, excessive internet use despite knowledge of related problems, use of the internet to escape or relieve a negative mood, and lying about internet use
“Results showed that PIU [pathological internet use] was significantly correlated with depression, conduct problems, hyperactivity, suicidal ideation and suicide attempts. Young people with PIU shared psychopathological factors with those having problematic alcohol use, in particular, depression and conduct problems.” (Wasserman 2016)
- early age of first sexual intercourse (Wasserman 2016)
- migration background (Wasserman 2016)



Suicide “postvention”
“There is now convincing empirical evidence that exposure to suicide increases the risk of subsequent suicide, as well as other negative mental health sequelae, in those who have been exposed. […]
[…] this substantial evidence base makes the compelling case that all suicide prevention programs need to include postvention services as a direct form of suicide prevention with a population of people known to be at heightened risk for suicide themselves: suicide loss survivors.” (Jordan 2017)



Odd (or not so odd) hypotheses about suicide
“Durkheim’s theory states that suicides decrease during wartime [but suicide rates did not decrease after the 911 terrorist attacks].” (Medenwald 2016)

From a study in Taiwan: “An unexpected […] finding is that people with an ongoing suicide attempt were less emotionally distressed than those with only suicidal thoughts.” (Shaw and Chiang 2018)

Suicide also occurs among non-human animals: “[…] sparse evidence supports some resemblance between the self-endangering behavior observed in the animal kingdom, particularly in animals held in captivity or put under pressure by environmental challenges, and suicidal behavior among humans.” (Preti 2007)
It is assumed that one risk factor for suicide is genetics – and our genetic information exists because it came to exist through evolution. So, it would be odd to find “suicide risk genes” exclusively in one single species, humans.
Behaviours in non-human animals that could be described as potential suicides:
- Self-endangering behaviour caused by parasitic infection
- Death by dispersal during migration
- Self-sacrifice on behalf of offspring or other relatives (altruistic behaviour)
- Death by starvation among pets after the death of their “master”
- Assault of a predator to protect offspring or other relatives
- Death by self-injury because of attempts to stop physical pain (Preti 2007)
“Among birds, strong competition is observed among siblings to gain parental resources. It has been proposed that as mortality by starvation increases, selection favors fratricide at first, then fratricide plus infanticide, and finally suicide by the nestling with the shortest life expectancy […].
[…] Animals sometimes take unnecessary risks in the presence of predators, but these behaviors can save a young close kin from assault […]. The oft-reported "suicidal behavior" of the lemmings, i.e., marching into the sea, is now interpreted as the result of dispersal: lemmings are considered the unfortunate victims of emigration in all directions, where death is incidental to the presence of geographic barriers […]. Some reports also describe the mass self-killing of birds flying into walls and lights as "suicide" […]. Nevertheless, this behavior could be simply a reflection of the birds' trying to get to safety in the presence of high winds […].
A stronger resemblance with the suicidal behavior in humans is the selfendangering behavior of certain butterfly species: adults or larvae were seen ostensibly to offer themselves to predators when senescent or when doomed to die by lethal internal parasites […].
[…] Infestation by parasites supposedly also explains the apparently voluntary stranding of whales, sometimes referred to as "suicide," and the death of ibexes, observed in high mountains when throwing themselves off cliffs.
[…] Aphids parasitized by aphidiine wasps often mummify outside the colony […]. Such behavior sometimes exposes the parasitized aphid to capture by ground beetles and other polyphagous predators […], thereby favoring dispersal of the parasite. However, in certain circumstances, the parasitized aphid reduces the risk of infesting its close kin, particularly when walking off of their plant, by wandering and dropping as a consequence of motor control impairment induced by the parasite, a mechanism sometimes referred to as hosts' suicide […].
Some authors even defined as "suicide" the fate of male praying mantises after copulation […].
[…] these behaviors [among spiders: if male dies after copulation] could be seen as adaptive ones, since they presumably improve reproductive fitness of the male's offspring. […] among redback spiders,
cannibalized males copulate longer and fertilize more eggs than those surviving copulation; moreover, females are more likely to reject subsequent suitors after consuming their first mate. […]
Among sexually cannibalistic praying mantises, males might sacrifice themselves to provide a nutritional supplement when insect food supplies are scarce, thereby assuring a larger and more viable batch of eggs. […]
[…] While anguish, despair, and rage often precede a suicide attempt and represent a driving force in human suicide, there is no evidence that animals, at least among mammals, are unaware of these feelings. Learned helplessness, which can be often elicited in laboratory animals, points towards some awareness of futility in nonhumans: the animal learns that its efforts are in vain and ceases them (although exhaustion could explain this unconditional surrender as well).
[…] Under extreme circumstances, animals subjected to extraordinary crowding, deprivation, or acute stress may sicken and die, refusing nourishment even when removed from distressing circumstances […].
[…] stories about dogs, and, less often, about cats who starve to death after the loss of a master to whom they were much attached […]. Under these circumstances a syndrome of severe malnutrition, selfmutilation, infection, and death was described […]. In folkloric tales, suicide following
the animal's mourning a loss is usually accomplished by starvation. However, the death of the animal, of a breed which develops a strong bond with the master, could depend upon the animal's reluctance to accept food from unknown people […].” (Preti 2007)



What is “altruistic suicide”?
It might seem surprising that altruism (i.e. wanting to help others without one’s own interest in mind) could be a cause for suicide. But “altruistic suicide” has been documented in a wide variety of different life circumstances.

- Altruistic suicide and Buddhism: Many cases of “[…] self-immolation as a form of political protest […]” (Kelly 2011) have been documented in the Buddhist context in East Asia (“massive numbers of dramatic public acts of self-immolation” in Vietnam and South Korea (Ben Park 2004)).
For example:
Thich Thien-An, a Buddhist monk imprisoned in Vietnam in 1963, was later asked about Buddhist self-immolations during this period and stated that the Buddhist self-immolations had succeeded in increasing international pressure on Vietnam, resulting in the release of some twenty thousand Buddhist monks, nuns, and professors who had been unjustly imprisoned.” (Kelly 2011)

Cover artwork of Rage Against The Machine’s first (and self-titled) album.
Explanation: “On 11 June 1963 Thich Quang Duc (1897–1963), a Vietnamese Buddhist monk, burned himself to death at a traffic intersection outside the Cambodian embassy in Saigon, Vietnam […].” (Kelly 2011) It is highly questionable if romanticizing altruistic suicide in this way is acceptable.

“[…] the Buddha stating that a true Bodhisattva (i.e., an individual who has obtained a specific and exceptionally high level of spiritual advancement) might sacrifice his body and life in order to end the suffering of others, bring peace and happiness to others, eliminate his own attachments to his body, or repay the kindness of his parents […].
This is not, however, an unqualified endorsement of self-harm, or even an excuse for bodily carelessness amongst Bodhisattvas, since the Bodhisattva, in order to protect the Dharma (Buddhist teachings), should care for his own body and life as the body is essential for spreading the Dharma [Buddha’s teachings][…].” (Kelly 2011)
- Altruistic suicide as a form of political protest unrelated to Buddhism has occurred in many countries,
including “Mass clusters of copycat altruistic self-burning promotion in the Middle East and North Africa” (Zarghami 2012).
The vegan animal rights movement has at least one famous case of a kind of altruistic suicide. Barry Horne, a vegan animal rights activist from England, died in on 5 November 2001 as a consequence of a series of long hunger strikes with which he wanted to convince the government to take several promised steps for non-human animals. However, unlike Thich Quang Duc (see above) Barry Horne did not achieve any political change with his death. After Horne’s death the British newspaper The Guardian wrote in classic right-wing jargon: “In life he was a nobody, a failed dustman turned firebomber.” (Toolis 2001) One can only feel embarrassed for The Guardian.

Barry Horne

- Altruistic suicide by prisoners in concentration camps in Nazi Germany
An example:
“[…] prisoners of the Auschwitz-Birkenau concentration camp […]. Suicides committed from patriotic or altruistic motives testified to the fact that human beings were able to preserve their dignity even in the face of death. […] The case of Father Maksymilian Kolbe […] who died of starvation of his own free will, […]. Father Kolbe expressed his readiness to undertake
death by starvation, a sentence passed on someone else.” (Ryn 1986)
- Altruistic suicide in ancient Greece:
“‘Herodotus: The Histories’ is a history of the rulers and soldiery who participated in the Greco-Persian wars (492–449 BCE). […] Other triggers of suicide included guilt, avoidance of dishonour/punishment and altruism. […] the deaths/ suicides of an unknown number of unnamed soldiers who starved on a long march. Lots were drawn and one in ten was cannibalized. The motives probably involved avoidance of starvation and altruism. […] Being a member of armed forces also increases the frequency of altruistic suicide.” (Pridmore et al. 2016)
“The sacrifice of one's life for the benefit of another, and in particular to defend one's country, was honored and admired in ancient Greek and Roman civilizations […].” (Preti 2007)
- Altruistic suicide among Arctic first nations
“Altruistic suicide, the self-sacrifice of one's own life to benefit a close kin, is documented among the Inuit during food shortage periods, as well as in some past ancient cultures, where men on the threshold of old age are supposed to have killed themselves so as not to become a burden for their relatives in case of illness […].” (Preti 2007)
- Altruistic suicide among modern day soldiers or people “fighting for a cause”
“In modern times altruistic suicide was identified in the soldiers dying on behalf of civilians or comrades […]. […] It may also be that people who endanger their lives under extreme circumstances do it under the influence of specific personality traits driving them to such behavior. […]” (Preti 2007)
“Altruistic suicide is found to be higher in more cohesive than in less cohesive groups and more likely among enlisted men than among career officers and noncommissioned officers.” (Blake 1978)
- Altruistic suicide among modern day individuals who do not want to be a burden
“[…] the indiscriminate use of modern life-sustaining technologies has led to an interest in voluntary euthanasia on the grounds of compassion and self determination and to a revived discussion of rational suicide. Proponents of rational suicide defend the practice as a competent decision when it is made on the basis of realistic beliefs and in the light of the person's fundamental interests and long-term values. The most obvious cases of rational suicide involve the termination of suffering, but [the author] also considers reasons other than self-interest. These include self-sacrificial suicides that advance altruistic values and expressive suicides that demonstrate a fundamental interest in a cause or situation.” (Mayo 1986)
The right to altruistic behaviour as a human right:
“[…] the dislike of losing independence and its closely associated wish to continue to behave altruistically. […] The rights to personal autonomy and to the practice of altruism are undisputed during competent adult life. Very strong arguments would be needed to justify the withdrawal of those rights from the dying.” (Davies 1993)



What does it have to do with veganism?
Let’s look at all the known risk factors for suicide listed above – and what they have to do with veganism and/or supporting the idea of animal rights.

Note: The following comments are not evidence-based. There is no scientific evidence here, because there are no studies on a potential link between veganism and suicide, and hopefully there will never be any studies of this kind (which would require a LOT of vegans anyway) because hopefully nothing will ever indicate that suicide rates are higher among vegans. From my personal experience I would assume (speculation) that suicide rates are not higher among vegans.

Note: For the sake of simplicity, I use the concept “vegans” (in general) and “vegan animal rights activists” (as a subgroup of vegans). I find this oversimplification useful in the context of this particular article.

Note: We can be vegans, i.e. we can obtain all nutrients we could possibly ever need in a vegan way. We do not need animal products. Vegans should pay some attention to several nutrients though, especially vitamin B12, see here.

Known risk factors in the general population and their connection to veganism:
MENTAL HEALTH PROBLEMS
- psychotic illness/hallucinations – Severe vitamin B12 deficiency can, in some people, lead to psychosis.
Vegans can easily avoid vitamin B12 deficiency by following science-based recommendations.
- depression – Living as a vegan in a non-vegan world that slaughters animals as if it was “all in good
taste” (even though “meat is murder”) could increase the risk of depression. What could lead to depression, for example, is disappointment with people for their refusal to become vegans, disappointment with vegan friends who stop being vegan, disappointment because of the lack of mutual support and encouragement within the vegan animal rights community, etc.
- anxiety – Being different could increase levels of anxiety.
- bipolar disorder – unclear connection to veganism
- post-traumatic stress disorder or neurosis – Could be related to veganism, possibly especially for animal
rights activists with high and/or direct exposure to animal suffering (for example on farms or in slaughterhouses).
- anorexia nervosa and other eating disorders – Likely no connection to veganism (Ways of thinking that
can lead to eating disorders can also lead to dietary restrictions (as one facet of the eating disorder), usually in the form of some kind of flexitarian diet. However, wrong information widely circulated within (but also outside of) the vegan community can lead to very restricted diets (such as raw vegan fruitarian diet). Such a diet (if too restricted and/or unsupplemented) can lead to severe nutrient deficiencies or even severe near-global malnutrition (deficiencies in many nutrients), and this could lead to eating disorders – whether this aetiology is an accurate description is uncertain however. It could also be that very wrong information can lead to severe dietary restrictions (based on the belief in the wrong information) and severe deficiencies in the absence of a psychological disorder (i.e. an actual eating disorder).
- mental illness in general – unclear connection to veganism
- psychological stress – Could be caused by being vegan in a non-vegan world. However, the opposite
could also be true. In fact, one study that included about 280 vegans found that “lower anxiety in males was related to a vegan diet and daily fruit and vegetable intake […] and lower stress in females was related to a vegan diet and lower daily intake of sweets.” (Beezhold et al. 2015)
PHYSICAL HEALTH PROBLEMS
- alcohol addiction – unclear connection to veganism
- certain medications – likely no connection to veganism
- physical illness that has led to disability – unclear connection to veganism, unless in the case of extreme
vitamin B12 deficiency and severe nerve damage which could in an extreme form make walking impossible (Brocadello et al. 2007).
- chronic pain/chronic illness in general – unclear connection to veganism, unless possibly in the case of
extreme vitamin B12 deficiency, other nutrient deficiencies or a general unhealthy diet and lifestyle
- chronic sleep disorders or lack of sufficient good sleep – unclear connection to veganism (A healthy diet
can improve sleep quality, however, and a vegan diet can be such a healthy diet (Campanini et al. 2017; St-Onge et al. 2016; St-Onge and Zuraikat 2019; St-Onge et al. 2018).)
- traumatic brain injury (in military personnel) – likely no connection to veganism
ABUSE FROM OTHERS
- experiencing discrimination – Vegans are frequently being discriminated against, just for being vegans
(Rosenfeld 2018; Horta 2018).
- experiencing personal conflict – Vegans are frequently attacked verbally and emotionally for being
vegans. Vegan animal rights activists might also be frequently attacked by other vegans with slightly different views.
- experiencing bullying (possibly especially “relational bullying” such as social exclusion or the spreading
of negative rumours) – Vegans are frequently bullied by non-vegans, possibly especially so in the form of relational bullying (social exclusion and spreading of negative rumours).
- experiencing violence/abuse in general (especially also sexual abuse in childhood) – unclear connection
to veganism
FEELINGS/SELF-PERCEPTION
- impulsivity – unclear connection to veganism (However, impulsivity is linked to diet, and a healthy diet
might decrease impulsive behaviour (Bénard et al. 2019; Stevenson 2017; Del-Ponte et al. 2019). “Impulsivity refers to a failure to withhold responses toward less valuable short-term goals […].” (Del-Ponte et al. 2019) That vegans living in a non-vegan world would be less prone to impulsivity, i.e. that they have more self-control, would not be surprising.)
- hopelessness – Witnessing the extent of animal suffering and the callous carelessness among the vast
majority of people can create a feeling of hopelessness.
- perceived social failure – Vegan animal rights activists might choose to dedicate their lives to helping
animals, which can lead to (what society might perceive as) social failure in terms career, financial circumstances, relationships, status symbols and what is generally perceived as the “good life”.
- shame – Vegans frequently experience finger pointing/stigmatization, discrimination, and negative
reactions to their vegan choices and views, as well as social exclusion because of veganism. This psychological burden might lead to shame.
- a sense of no purpose in life – Unclear connection to veganism, but vegan animal rights activists might
feel a sense of “uselessness” because of the overwhelming extent of animal suffering. On the contrary, vegan animal rights activists might feel a strong sense of purpose in life because of veganism.
- low self-esteem – Unclear connection to veganism, but vegans live in a non-vegan world that rejects
veganism, especially ethical veganism, and that frequently attacks vegans. This could lead to low self- esteem.
- self-blame – Could be the case for vegan animal rights activists who blame themselves for not doing
enough.
- concerns about own sexual orientation – likely no connection to veganism
LIFE CIRCUMSTANCES
- imprisonment – Unclear connection to veganism, but could be the case for vegan animal rights activists
who break the law, or for vegan parents who unwillingly end up causing severe malnutrition in their child (for example, because of wrong information such as home-made nut milk as a replacement for mother’s milk, not using vitamin B12 supplements, etc. … for nutrients vegans should pay attention to, see here)
- financial difficulties – Could be the case for vegans who dedicate their lives to activism (which often
does not pay or pay well).
- unemployment/very low income/loss of job – see “financial difficulties” above. Many vegans likely also
avoid certain types of employment and even careers because animals are used/harmed in these areas. Veganism could also lead to being fired from a job.
- a cultural background that accepts certain forms of suicide – likely no connection to veganism
- having no religion (or a religion that endorses certain forms of suicide) – unclear connection to
veganism … Having no religion might be more common among western vegans compared to western non-vegans (speculation)
- Caucasian ethnicity – unclear connection to veganism
- migration background (being a “foreigner” or being perceived as “foreign”) – unclear connection to
veganism
- female gender (or male gender) – unclear connection to veganism
- early age of first sexual intercourse – unclear connection to veganism
- divorce – Unclear connection to veganism, but might be related to being vegan, either with a non-
vegan ex-partner or a vegan ex-partner. Might be related to higher levels of psychological stress/trauma (if applicable) among vegans or vegan animal rights activists, relationships based more on political alliance rather than a deep personal connection, higher mobility (moving to a different/distant location; if applicable) among vegans, moral conflicts between a vegan and a non-vegan partner, etc.
- relationship break-up – Unclear connection to veganism, but might be related to being vegan, either
with a non-vegan ex-partner or a vegan ex-partner (see above: divorce)
- loss of a relative/friend by suicide – Unclear connection to veganism, unless suicide rates were higher
among vegans in general, or among vegan animal activists specifically – something which we do not know.
- advanced age – Unclear connection to veganism, but getting older as a vegan, possibly combined with
social isolation, and vegan-specific challenges such as getting vegan food, vegan clothing, vegan bedding, etc., staying vegan with reduced mobility, maintaining good health and/or strength without vegan-friendly support and without moral support, can be a huge challenge.
- traumatic life events/loss of a loved one (for example one’s life partner) – Unclear connection to
veganism, but living as a person sensitive to animal suffering in a non-vegan world can be traumatic.
- social isolation – can be the case for vegans
- excessive work load – Unclear connection to veganism, but can be the case for animal rights activists
who often think that the extent of animal suffering is so huge that one can never work hard enough.
- divorce of parents – unclear connection to veganism
- dysfunctional family – unclear connection to veganism
- possibly: living in a wealthier family – unclear connection to veganism
- belonging to a minority – Vegans are obviously a very small minority. But as vegans we furthermore
belong to the “vegan minority” by choice. This can be an advantage (compared to belonging to a minority that you did not choose to belong to), but it can also be a disadvantage, because people might especially dislike and attack your for choosing to be different, by making different choices, choices that we as vegans claim are morally preferable, i.e. “superior” – this can create anger and resentment in non-vegans.
- being illiterate – very likely uncommon among vegans
- negative life experiences – Living in a world that condones and endorses slaughterhouses, even though
they are unnecessary for producing affordable, healthy and delicious food, is a negative experience that is always present in the back of your head – if you are a vegan.
- availability of a firearm or other “lethal means” that could be used to commit suicide – unclear
connection to veganism
BEHAVIOUR
- self-harm behaviours (excessive alcohol, smoking, drugs, intentional self-inflicted damage to the
surface of one’s body, for example by self-cutting, self-burning, self-hitting, self-biting, etc.) – unclear connection to veganism
- pathological internet use – Unclear connection to veganism, however, some vegan animal rights
activists might perceive it as a moral duty to spend excessive amounts of time (excessive for good health) on the internet researching or trying to communicate on social media.


Potential vegan-specific risk factors:
- Potentially shallow friendships in the animal rights movement, based on political alliance rather than a
deep personal connection – no unwanted views welcome, closed-mindedness, sectarianism.
- Awareness of animal suffering can create despair. Some vegan animal rights activists perceive it as their
moral duty to remind themselves on a daily basis of the unbearable extent of animal suffering.
- The rhetoric of revolution and struggle can create despair. Rationally speaking, a worldwide vegan
revolution will likely never happen, quite certainly not within our lifetimes. But even if humans started doing everything right, the entire human world population would go vegan etc., the world would still be a terrible place. Nature, for example, is a place of terrible cruelty. Life itself is the journey to death, and full of suffering. But - paradoxically - I am quite sure (personal opinion) that it is possible to live a happy life, even being aware of the extent of animal suffering and “fighting the good fight” (maybe not in these words).
- Nutrition: Vegan nutrition is an important topic for the mental health of vegans.
- The view that taking good care of yourself and trying to be healthy is “selfish” is held by a considerable
number of people in the animal rights movement.
- High levels of toxic perfectionism in the animal rights movement.
- High levels of criticism of peers combined with an inability to communicate clearly and inoffensively
(common everywhere) in the animal rights movement – stigmatization within the animal rights movement.
- High levels of cultural heterogeneity within the animal rights movement – this could lead to
misunderstandings, culture shock, frustration, etc.
- Being vegan could potentially make it more difficult to find a life partner (among non-vegans). It could
theoretically also make it easier to find a life partner (among fellow vegans), because of veganism as a shared important world view among vegans. However, potentially shallow relationships in the animal rights movement, based on political alliance rather than a deep personal connection (see first point of this paragraph).
- Potentially a higher percentage of people who do not want children among vegan animal rights
activists. This likely makes it more difficult to find a life partner among non-vegans/non-animal rights activists.
- If applicable: With the increased difficulty to find a life partner, an increased feeling of being alone,
potentially intensified by criticism and alienation from non-vegan friends and family.
- Altruistic suicide for non-human animals (see the example of Barry Horne above in “What is ‘altruistic suicide’?”)


Potential society-wide causal factors for risk factors:
- Our society is based on extreme individualism that rewards taking advantage of others.
- Our society is dominated by self-destructive behaviour. Suicide is just the tip of the iceberg.
- Our society does not offer coping mechanisms for suicidality. Frequently people say: “If you feel suicidal
then talk to a friend.” However, friends and family often respond with “Stop whining”, “Get your life together”, “Stop being negative”, etc. and/or react with avoiding the suicidal person seeking help. Medical practitioners typically respond with the prescription of anti-depressant medication, “trapping” patients in a vicious cycle of medication-dependence and deteriorating health (Sobieraj et al. 2019; Aguiar et al. 2019; Giatti et al. 2018; Montejo et al. 2015; Elnazer et al. 2015; Gartlehner et al. 2019; Clayton et al. 2014) without addressing potentially adjustable life circumstances.


Potentially protective factors against suicide in the general population and their applicability to the vegan animal rights movement:
- a sense of community/belonging – A sense of community might be found in the vegan and vegan animal rights communities, but being very heterogenous movements with many strong opinions this sense is often absent.


- religion – Many vegans are religious, especially in East Asia but also in the rest of the world. Among “reason-based” vegans, often very rational people, it seems safe to assume that having no religion is common. It might be important to find alternative coping strategies (to cope with life) for rational vegans. 



Studies on vegetarian diet and suicide risk
As mentioned above, there are no studies on whether suicide rates among vegans could be higher or lower compared to the general population. Such studies would require a lot of vegans and very long follow-up.

- A study from Twin Cities area in Minnesota (USA) with about 4700 students, 11 to 18 years old, including 94 vegetarians (ovo-lacto-vegetarians, lacto-vegetarians, and vegans – number of vegans not given) and with data from 1998/1999 found that the percentage of students who answered “yes” to “Thought about killing yourself” and “Ever tried to kill yourself” was higher among vegetarians and chicken/fish-eating red meat avoiders compared to typical non-vegetarians.
About 35% of the vegetarian/chicken-/fish-eating (red meat avoiding) group reported to have had suicidal thoughts, compared to 25% of the typical non-vegetarians.
About 18% of the vegetarian/chicken-/fish-eating (red meat avoiding) group reported to have tried to commit suicide, compared to 9% of the typical non-vegetarians.
There was no difference regarding the prevalence of suicidal thoughts or suicide attempts between the vegetarian group and the chicken-/fish-eating red meat avoider group. The main reasons for avoiding meat in both of these groups was, first wanting to lose weight/not gain weight, and second not wanting to kill animals.
The red meat avoiders (vegetarians + chicken-/fish-eating red meat avoiders) had a much higher percentage of females, a higher percentage of Caucasians, and were on average younger, compared to the typical non-vegetarians (Perry et al. 2001).

- An earlier study by the same working group with students aged 12 to 20 years, from the same area in Minnesota, including 107 “vegetarians” (a mix of vegetarians and chicken-/fish-eating red meat avoiders*), with data from 1986/1987 found that 25% of the red meat avoiders and 17% of the typical non-vegetarians reported past suicide attempts, i.e. they answered “yes” to “Have you ever tried to kill yourself?”. (In this article no information is given on whether this difference was statistically significant.) (Neumark-Sztainer et al. 1997).
* 40% of the red meat avoiders, i.e. about 42 or 43 of the 107 red meat avoiders, seem to have been vegetarians. Some (about 17% ) of the “vegetarians” (red meat avoiders) sometimes also ate red meat (Neumark-Sztainer et al. 1997).

What these two studies from one area tell us is not much. But what they seem to indicate is that the reason for the higher rates of suicidal thoughts and suicide attempts among red meat avoiders compared to typical non-vegetarians was not related to nutrient intake. What this might indicate (speculation) is that vegetarian and red meat avoiding teenagers might face specific challenges such as stigmatization and/or social exclusion. It might also indicate (speculation) that certain ways of thinking/feeling, that might include thinking about life and death, might predispose these individuals to thinking about healthy eating and/or about killing animals for food as well as to considering suicide.

Knowing so little about suicide rates among vegans (nothing from studies), while we do know of stigmatization, bullying and social exclusion of (and among) vegans, attention should be paid to vegan-specific risk factors (see “What does it have to do with veganism?” above). It is also possible that vegan teenagers specifically need more support in this area, and it is furthermore possible that female teenagers (and females in general) are more vulnerable to the negative consequences of social exclusion (speculation) (Cruz et al. 2017; Galen and Underwood 1997) or bullying (Betts et al. 2017) and that female vegans might be bullied more often than male vegans. Interestingly, … and what your grandmother might have already told you anyway, more physical activity can make you happy and more physical activity can be a “a potential strategy for helping individuals cope with negative social experiences” (Delli Paoli et al. 2017).



Take home messages
- Society in general should address suicide as an important and urgent public health problem.

- Society in general should aim to diminish stigmatization, bullying and discrimination, including
stigmatization, bullying and discrimination of vegans.

- The vegan and vegan animal rights communities should make the mental health of vegans a priority
and discuss it as an important and multi-facetted issue.

- The vegan and vegan animal rights communities should embrace approaches to living that favour long-
term happiness in vegans.

- You … should jump around more (a lot more).



The End
The Albert Schweitzer quote from the beginning of this post, continues with a slightly odd sentence structure (my translation from the original German):

“The one who dares to think, however, who queries existence, who tries to grasp the meaning of the life that he carries, who witnesses the suffering of the world, … he knows the hours in which the horror of existence is stronger to him than the horror of not existing anymore, … although he might seem like a happy, perhaps even a fun-loving person to others, and where the temptation to end his life in some way or other approaches him. You walk beside people and you suppose that you know them, but you do not know them, because you do not know that they have lived through such hours, in which they wavered, whether to decide for being or for not being anymore.” Albert Schweitzer (Brüllmann and Gräßer 2001)

(Brüllmann and Gräßer 2001)



Suicide is not a solution to your problems. When you feel like you just want the pain to stop, what you are longing for is a feeling of relief, a relief from all the pain. You will never find this feeling in death. If you die, you will never feel anything anymore, forever. If you survive, the feeling of relief will come one day – if you survive.








References
Aguiar, João Pedro; Brito, Ana Mafalda; Martins, Ana Paula; Leufkens, Hubert G. M.; Alves da Costa, Filipa (2019): Potentially inappropriate medications with risk of cardiovascular adverse events in the elderly: A systematic review of tools addressing inappropriate prescribing. In Journal of clinical pharmacy and therapeutics. DOI: 10.1111/jcpt.12811.
Beezhold, Bonnie; Radnitz, Cynthia; Rinne, Amy; DiMatteo, Julie (2015): Vegans report less stress and anxiety than omnivores. In Nutritional neuroscience 18 (7), pp. 289–296. DOI: 10.1179/1476830514Y.0000000164.
Ben Park, B. C. (2004): Sociopolitical contexts of self-immolations in Vietnam and South Korea. In Archives of suicide research : official journal of the International Academy for Suicide Research 8 (1), pp. 81–97. DOI: 10.1080/138111110490243796.
Bénard, Marc; Bellisle, France; Kesse-Guyot, Emmanuelle; Julia, Chantal; Andreeva, Valentina A.; Etilé, Fabrice et al. (2019): Impulsivity is associated with food intake, snacking, and eating disorders in a general population. In The American journal of clinical nutrition 109 (1), pp. 117–126. DOI: 10.1093/ajcn/nqy255.
Berardis, Domenico de; Fornaro, Michele; Valchera, Alessandro; Cavuto, Marilde; Perna, Giampaolo; Di Nicola, Marco et al. (2018): Eradicating Suicide at Its Roots. Preclinical Bases and Clinical Evidence of the Efficacy of Ketamine in the Treatment of Suicidal Behaviors. In International journal of molecular sciences 19 (10). DOI: 10.3390/ijms19102888.
Betts, Lucy R.; Spenser, Karin A.; Gardner, Sarah E. (2017): Adolescents' Involvement in Cyber Bullying and Perceptions of School: The Importance of Perceived Peer Acceptance for Female Adolescents. In Sex roles 77 (7), pp. 471–481. DOI: 10.1007/s11199-017-0742-2.
Bhimji, Steve S.; Dulebohn, Scott C. (2018): StatPearls. Suicide Screening and Prevention. Treasure Island (FL).
Blake, J. A. (1978): Death by hand grenade: altruistic suicide in combat. In Suicide & life-threatening behavior 8 (1), pp. 46–59.
Borges, G.; Bagge, C. L.; Cherpitel, C. J.; Conner, K. R.; Orozco, R.; Rossow, I. (2017): A meta-analysis of acute use of alcohol and the risk of suicide attempt. In Psychological medicine 47 (5), pp. 949–957. DOI: 10.1017/S0033291716002841.
Brocadello, Filippo; Levedianos, Giorgio; Piccione, Francesco; Manara, Renzo; Pesenti, Francesco Francini (2007): Irreversible subacute sclerotic combined degeneration of the spinal cord in a vegan subject. In Nutrition (Burbank, Los Angeles County, Calif.) 23 (7-8), pp. 622–624. DOI: 10.1016/j.nut.2007.05.006.
Brüllmann, Richard; Gräßer, Erich (Eds.) (2001): Albert Schweitzer. Predigten 1898–1948. 3406469973rd ed. München: Verlag C. H. Beck.
Campanini, Marcela Z.; Guallar-Castillón, Pilar; Rodríguez-Artalejo, Fernando; Lopez-Garcia, Esther (2017): Mediterranean Diet and Changes in Sleep Duration and Indicators of Sleep Quality in Older Adults. In Sleep 40 (3). DOI: 10.1093/sleep/zsw083.
CDC (2019): Fatal Injury Reports, National, Regional and State, 1981 - 2017. WISQARS™ WISQARS Home > Fatal Injury Data. Available online at https://webappa.cdc.gov/sasweb/ncipc/mortrate.html, checked on 4/14/2019.
Chen, Justin A.; Courtwright, Andrew; Wu, Kevin Chien-Chang (2017): The Role of Stigma and Denormalization in Suicide-Prevention Laws in East Asia. A Sociocultural, Historical, and Ethical Perspective. In Harvard review of psychiatry 25 (5), pp. 229–240. DOI: 10.1097/HRP.0000000000000160.
Clayton, Anita H.; Croft, Harry A.; Handiwala, Lata (2014): Antidepressants and sexual dysfunction: mechanisms and clinical implications. In Postgraduate medicine 126 (2), pp. 91–99. DOI: 10.3810/pgm.2014.03.2744.
Coppersmith, Glen; Leary, Ryan; Crutchley, Patrick; Fine, Alex (2018): Natural Language Processing of Social Media as Screening for Suicide Risk. In Biomedical informatics insights 10, 1178222618792860. DOI: 10.1177/1178222618792860.
Costa, Lucas da Silva; Alencar, Átila Pereira; Nascimento Neto, Pedro Januário; dos Santos, Maria do Socorro Vieira; da Silva, Cláudio Gleidiston Lima; Pinheiro, Sally de França Lacerda et al. (2015): Risk factors for suicide in bipolar disorder: a systematic review. In Journal of affective disorders 170, pp. 237–254. DOI: 10.1016/j.jad.2014.09.003.
Cramer, Robert J.; Kapusta, Nestor D. (2017): A Social-Ecological Framework of Theory, Assessment, and Prevention of Suicide. In Frontiers in psychology 8, p. 1756. DOI: 10.3389/fpsyg.2017.01756.
Cramer, Robert J.; Wechsler, Hayley J.; Miller, Sarah L.; Yenne, Elise (2017): Suicide Prevention in Correctional Settings. Current Standards and Recommendations for Research, Prevention, and Training. In Journal of correctional health care : the official journal of the National Commission on Correctional Health Care 23 (3), pp. 313–328. DOI: 10.1177/1078345817716162.
Cruz, Elisabeth Lima Dias da; Martins, Priscila Diniz de Carvalho; Diniz, Paula Rejane Beserra (2017): Factors related to the association of social anxiety disorder and alcohol use among adolescents: a systematic review. In Jornal de pediatria 93 (5), pp. 442–451. DOI: 10.1016/j.jped.2017.05.001.
Davies, J. (1993): Altruism towards the end of life. In Journal of medical ethics 19 (2), pp. 111–113.
Delli Paoli, Anthony G.; Smith, Alan L.; Pontifex, Matthew B. (2017): Does Walking Mitigate Affective and Cognitive Responses to Social Exclusion? In Journal of sport & exercise psychology 39 (2), pp. 97–108. DOI: 10.1123/jsep.2016-0202.
Del-Ponte, Bianca; Quinte, Gabriela Callo; Cruz, Suélen; Grellert, Merlen; Santos, Iná S. (2019): Dietary patterns and attention deficit/hyperactivity disorder (ADHD): A systematic review and meta-analysis. In Journal of affective disorders 252, pp. 160–173. DOI: 10.1016/j.jad.2019.04.061.
Disayavanish, Chamlong; Disayavanish, Primprao (2007): A Buddhist approach to suicide prevention. In Journal of the Medical Association of Thailand = Chotmaihet thangphaet 90 (8), pp. 1680–1688.
Elnazer, Hesham Y.; Sampson, Anthony; Baldwin, David (2015): Lithium and sexual dysfunction: an under-researched area. In Human psychopharmacology 30 (2), pp. 66–69. DOI: 10.1002/hup.2457.
Fang, Chun-Kai; Lu, Hsin-Chin; Liu, Shen-ing; Sun, Yi-Wen (2011): Religious beliefs along the suicidal path in northern Taiwan. In Omega 63 (3), pp. 255–269. DOI: 10.2190/OM.63.3.d.
Galen, B. R.; Underwood, M. K. (1997): A developmental investigation of social aggression among children. In Developmental psychology 33 (4), pp. 589–600.
Gambadauro, Pietro; Carli, Vladimir; Wasserman, Camilla; Hadlaczky, Gergö; Sarchiapone, Marco; Apter, Alan et al. (2018): Psychopathology is associated with reproductive health risk in European adolescents. In Reproductive health 15 (1), p. 186. DOI: 10.1186/s12978-018-0618-0.
Gartlehner, Gerald; Nussbaumer-Streit, Barbara; Gaynes, Bradley N.; Forneris, Catherine A.; Morgan, Laura C.; Greenblatt, Amy et al. (2019): Second-generation antidepressants for preventing seasonal affective disorder in adults. In The Cochrane database of systematic reviews 3, CD011268. DOI: 10.1002/14651858.CD011268.pub3.
Gearing, Robin Edward; Alonzo, Dana (2018): Religion and Suicide. New Findings. In Journal of religion and health. DOI: 10.1007/s10943-018-0629-8.
Giatti, Silvia; Diviccaro, Silvia; Panzica, Giancarlo; Melcangi, Roberto Cosimo (2018): Post-finasteride syndrome and post-SSRI sexual dysfunction: two sides of the same coin? In Endocrine 61 (2), pp. 180–193. DOI: 10.1007/s12020-018-1593-5.
Goldblatt, Mark J.; Ronningstam, Elsa; Schechter, Mark; Herbstman, Benjamin; Maltsberger, John T. (2016): Suicide as escape from psychotic panic. In Bulletin of the Menninger Clinic 80 (2), pp. 131–145. DOI: 10.1521/bumc.2016.80.2.131.
Gunnell, David; Knipe, Duleeka; Chang, Shu-Sen; Pearson, Melissa; Konradsen, Flemming; Lee, Won Jin; Eddleston, Michael (2017): Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides. A systematic review of the international evidence. In The Lancet. Global health 5 (10), e1026-e1037. DOI: 10.1016/S2214-109X(17)30299-1.
Horta, Oscar (2018): Discrimination Against Vegans. In Res Publica 24 (3), pp. 359–373. DOI: 10.1007/s11158-017-9356-3.
Johnson, Sheri L.; Carver, Charles S.; Tharp, Jordan A. (2017): Suicidality in Bipolar Disorder: The Role of Emotion-Triggered Impulsivity. In Suicide & life-threatening behavior 47 (2), pp. 177–192. DOI: 10.1111/sltb.12274.
Jordan, John R. (2017): Postvention is prevention-The case for suicide postvention. In Death studies 41 (10), pp. 614–621. DOI: 10.1080/07481187.2017.1335544.
Jung, JaeHoon; Roh, Daeyoung; Moon, Yoo Sun; Kim, Do Hoon (2017): The Moderating Effect of Religion on the Relationship Between Depression and Suicidal Ideation in the Elderly. In The Journal of nervous and mental disease 205 (8), pp. 605–610. DOI: 10.1097/NMD.0000000000000637.
Kelly, Brendan D. (2011): Self-immolation, suicide and self-harm in Buddhist and Western traditions. In Transcultural psychiatry 48 (3), pp. 299–317. DOI: 10.1177/1363461511402869.
King, Cheryl A.; Arango, Alejandra; Ewell Foster, Cynthia (2018): Emerging trends in adolescent suicide prevention research. In Current opinion in psychology 22, pp. 89–94. DOI: 10.1016/j.copsyc.2017.08.037.
Koseki, K. (1990): Selective conservatism in the management of abdominal stab wounds. In Nihon Geka Gakkai zasshi 91 (8), pp. 950–958.
Latalova, Klara; Kamaradova, Dana; Prasko, Jan (2014): Suicide in bipolar disorder: a review. In Psychiatria Danubina 26 (2), pp. 108–114.
Le, Minh Thi Hong; Nguyen, Huong Thanh; Tran, Thach Duc; Fisher, Jane R. W. (2012): Experience of low mood and suicidal behaviors among adolescents in Vietnam. Findings from two national population-based surveys. In The Journal of adolescent health : official publication of the Society for Adolescent Medicine 51 (4), pp. 339–348. DOI: 10.1016/j.jadohealth.2011.12.027.
Lévy, Benjamin T.; Prudent, Cécile; Liétard, Florian; Evrard, Renaud (2017): From Querulous to Suicidal: Self-immolation in Public Places as a Symbolic Response to the Feeling of Injustice. In Frontiers in psychology 8, p. 1901. DOI: 10.3389/fpsyg.2017.01901.
Lian, Qiguo; Zuo, Xiayun; Mao, Yanyan; Luo, Shan; Zhang, Shucheng; Tu, Xiaowen et al. (2017): Anorexia nervosa, depression and suicidal thoughts among Chinese adolescents: a national school-based cross-sectional study. In Environmental health and preventive medicine 22 (1), p. 30. DOI: 10.1186/s12199-017-0639-2.
Lima, Isabela M. M.; Peckham, Andrew D.; Johnson, Sheri L. (2018): Cognitive deficits in bipolar disorders: Implications for emotion. In Clinical psychology review 59, pp. 126–136. DOI: 10.1016/j.cpr.2017.11.006.
Lizardi, D.; Gearing, R. E. (2010): Religion and suicide. Buddhism, Native American and African religions, Atheism, and Agnosticism. In Journal of religion and health 49 (3), pp. 377–384. DOI: 10.1007/s10943-009-9248-8.
Maiese, Aniello; Gitto, Lorenzo; dell'Aquila, Massimiliano; Bolino, Giorgio (2014): A peculiar case of suicide enacted through the ancient Japanese ritual of Jigai. In The American journal of forensic medicine and pathology 35 (1), pp. 8–10. DOI: 10.1097/PAF.0000000000000070.
Mann, J. John; Michel, Christina A. (2016): Prevention of Firearm Suicide in the United States: What Works and What Is Possible. In The American journal of psychiatry 173 (10), pp. 969–979. DOI: 10.1176/appi.ajp.2016.16010069.
Mayo, D. J. (1986): The concept of rational suicide. In The Journal of medicine and philosophy 11 (2), pp. 143–155.
Medenwald, Daniel (2016): The Terror Attacks of 9/11 and Suicides in Germany. A Time Series Analysis. In Medicine 95 (15), e3228. DOI: 10.1097/MD.0000000000003228.
Montejo, Angel L.; Montejo, Laura; Navarro-Cremades, Felipe (2015): Sexual side-effects of antidepressant and antipsychotic drugs. In Current opinion in psychiatry 28 (6), pp. 418–423. DOI: 10.1097/YCO.0000000000000198.
Moradinazar, Mehdi; Amini, Saeed; Baneshi, Mohammadreza; Najafi, Farid; Abbasi, Nikzad; Ataee, Mari (2016): Survival probability in self immolation attempters: a prospective observational cohort study. In Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES 22 (1), pp. 23–28. DOI: 10.5505/tjtes.2015.96155.
Musci, Rashelle J.; Kharrazi, Hadi; Wilson, Renee F.; Susukida, Ryoko; Gharghabi, Fardad; Zhang, Allen et al. (2018): The study of effect moderation in youth suicide-prevention studies. In Social psychiatry and psychiatric epidemiology. DOI: 10.1007/s00127-018-1574-2.
Nelson, Heidi D.; Denneson, Lauren M.; Low, Allison R.; Bauer, Brian W.; O'Neil, Maya; Kansagara, Devan; Teo, Alan R. (2017): Suicide Risk Assessment and Prevention. A Systematic Review Focusing on Veterans. In Psychiatric services (Washington, D.C.) 68 (10), pp. 1003–1015. DOI: 10.1176/appi.ps.201600384.
Neumark-Sztainer, D.; Story, M.; Resnick, M. D.; Blum, R. W. (1997): Adolescent vegetarians. A behavioral profile of a school-based population in Minnesota. In Archives of pediatrics & adolescent medicine 151 (8), pp. 833–838.
Ng, Qin Xiang; Yong, Bob Zheng Jie; Ho, Collin Yin Xian; Lim, Donovan Yutong; Yeo, Wee-Song (2018): Early life sexual abuse is associated with increased suicide attempts: An update meta-analysis. In Journal of psychiatric research 99, pp. 129–141. DOI: 10.1016/j.jpsychires.2018.02.001.
Niethammer, Rainer; Breitmaier, Jörg (2005): Selbstverbrennung als Versuch der Selbstrettung im Rahmen einer psychotischen Episode. In Psychiatrische Praxis 32 (5), pp. 252–254. DOI: 10.1055/s-2004-828366.
Oexle, N.; Rüsch, N. (2018): Stigma – Risikofaktor und Konsequenz suizidalen Verhaltens. Implikationen für die Suizidprävention. In Der Nervenarzt 89 (7), pp. 779–783. DOI: 10.1007/s00115-017-0450-8.
Parvareh, Maryam; Hajizadeh, Mohammad; Rezaei, Satar; Nouri, Bijan; Moradi, Ghobad; Esmail Nasab, Nader (2018): Epidemiology and socio-demographic risk factors of self-immolation. A systematic review and meta-analysis. In Burns : journal of the International Society for Burn Injuries 44 (4), pp. 767–775. DOI: 10.1016/j.burns.2017.08.013.
Perry, C. L.; Mcguire, M. T.; Neumark-Sztainer, D.; Story, M. (2001): Characteristics of vegetarian adolescents in a multiethnic urban population. In The Journal of adolescent health : official publication of the Society for Adolescent Medicine 29 (6), pp. 406–416.
Picone, Mary (2012): Suicide and the afterlife. Popular religion and the standardisation of 'culture' in Japan. In Culture, medicine and psychiatry 36 (2), pp. 391–408. DOI: 10.1007/s11013-012-9261-3.
Preti, Antonio (2007): Suicide among animals: a review of evidence. In Psychological reports 101 (3 Pt 1), pp. 831–848. DOI: 10.2466/pr0.101.3.831-848.
Pridmore, Saxby; Auchincloss, Stephane; Ahmadi, Jamshid (2016): Suicide Triggers Described by Herodotus. In Iranian journal of psychiatry 11 (2), pp. 128–132.
Rodríguez Andrés, Antonio; Hempstead, Katherine (2011): Gun control and suicide: the impact of state firearm regulations in the United States, 1995-2004. In Health policy (Amsterdam, Netherlands) 101 (1), pp. 95–103. DOI: 10.1016/j.healthpol.2010.10.005.
Romm, Sharon; Combs, Heidi; Klein, Matthew B. (2008): Self-immolation: cause and culture. In Journal of burn care & research : official publication of the American Burn Association 29 (6), pp. 988–993. DOI: 10.1097/BCR.0b013e31818b9ed4.
Rosenfeld, Daniel L. (2018): The psychology of vegetarianism: Recent advances and future directions. In Appetite 131, pp. 125–138. DOI: 10.1016/j.appet.2018.09.011.
Rothschild, M. A.; Raatschen, H. J.; Schneider, V. (2001): Suicide by self-immolation in Berlin from 1990 to 2000. In Forensic science international 124 (2-3), pp. 163–166.
Ryn, Z. (1986): Suicides in the Nazi concentration camps. In Suicide & life-threatening behavior 16 (4), pp. 419–433.
Sampasa-Kanyinga, Hugues; Dupuis, Lorette C.; Ray, Robin (2017): Prevalence and correlates of suicidal ideation and attempts among children and adolescents. In International journal of adolescent medicine and health 29 (2). DOI: 10.1515/ijamh-2015-0053.
Shaw, Fortune Fu-Tsung; Chiang, Wen-Hsien (2018): An evaluation of suicide prevention hotline results in Taiwan. Caller profiles and the effect on emotional distress and suicide risk. In Journal of affective disorders 244, pp. 16–20. DOI: 10.1016/j.jad.2018.09.050.
Sinyor, Mark; Schaffer, Ayal; Redelmeier, Donald A.; Kiss, Alex; Nishikawa, Yasunori; Cheung, Amy H. et al. (2017): Did the suicide barrier work after all? Revisiting the Bloor Viaduct natural experiment and its impact on suicide rates in Toronto. In BMJ open 7 (5), e015299. DOI: 10.1136/bmjopen-2016-015299.
Smith, April R.; Zuromski, Kelly L.; Dodd, Dorian R. (2018): Eating disorders and suicidality: what we know, what we don't know, and suggestions for future research. In Current opinion in psychology 22, pp. 63–67. DOI: 10.1016/j.copsyc.2017.08.023.
Sobieraj, Diana M.; Baker, William L.; Martinez, Brandon K.; Hernandez, Adrian v.; Coleman, Craig I.; Ross, Joseph S. et al. (2019): Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults. Rockville (MD).
Stevenson, Richard J. (2017): Psychological correlates of habitual diet in healthy adults. In Psychological bulletin 143 (1), pp. 53–90. DOI: 10.1037/bul0000065.
St-Onge, Marie-Pierre; Crawford, Allison; Aggarwal, Brooke (2018): Plant-based diets: Reducing cardiovascular risk by improving sleep quality? In Current sleep medicine reports 4 (1), pp. 74–78.
St-Onge, Marie-Pierre; Mikic, Anja; Pietrolungo, Cara E. (2016): Effects of Diet on Sleep Quality. In Advances in nutrition (Bethesda, Md.) 7 (5), pp. 938–949. DOI: 10.3945/an.116.012336.
St-Onge, Marie-Pierre; Zuraikat, Faris M. (2019): Reciprocal Roles of Sleep and Diet in Cardiovascular Health: a Review of Recent Evidence and a Potential Mechanism. In Current atherosclerosis reports 21 (3), p. 11. DOI: 10.1007/s11883-019-0772-z.
Tan, Ling; Xia, Tiansheng; Reece, Christy (2018): Social and individual risk factors for suicide ideation among Chinese children and adolescents. A multilevel analysis. In International journal of psychology : Journal international de psychologie 53 (2), pp. 117–125. DOI: 10.1002/ijop.12273.
The Lancet (2017): Gun deaths and the gun control debate in the USA. In Lancet (London, England) 390 (10105), p. 1812. DOI: 10.1016/S0140-6736(17)32710-1.
Thornton, Laura M.; Welch, Elisabeth; Munn-Chernoff, Melissa A.; Lichtenstein, Paul; Bulik, Cynthia M. (2016): Anorexia Nervosa, Major Depression, and Suicide Attempts: Shared Genetic Factors. In Suicide & life-threatening behavior 46 (5), pp. 525–534. DOI: 10.1111/sltb.12235.
Toolis, Kevin (2001): To the death. Edited by The Guardian. Available online at https://www.theguardian.com/g2/story/0,,588987,00.html., checked on 4/20/2019.
Torous, John; Larsen, Mark E.; Depp, Colin; Cosco, Theodore D.; Barnett, Ian; Nock, Matthew K.; Firth, Joe (2018): Smartphones, Sensors, and Machine Learning to Advance Real-Time Prediction and Interventions for Suicide Prevention. A Review of Current Progress and Next Steps. In Current psychiatry reports 20 (7), p. 51. DOI: 10.1007/s11920-018-0914-y.
Wasserman, Danuta (2016): Review of health and risk-behaviours, mental health problems and suicidal behaviours in young Europeans on the basis of the results from the EU-funded Saving and Empowering Young Lives in Europe (SEYLE) study. In Psychiatria polska 50 (6), pp. 1093–1107. DOI: 10.12740/PP/66954.
WHO (2018): Suicide. Available online at http://www.who.int/news-room/fact-sheets/detail/suicide, updated on 8/24/2018, checked on 4/7/2019.
Wu, Kevin Chien-Chang; Chen, Ying-Yeh; Yip, Paul S. F. (2012): Suicide methods in Asia. Implications in suicide prevention. In International journal of environmental research and public health 9 (4), pp. 1135–1158. DOI: 10.3390/ijerph9041135.
Xuan, Ziming; Naimi, Timothy S.; Kaplan, Mark S.; Bagge, Courtney L.; Few, Lauren R.; Maisto, Stephen et al. (2016): Alcohol Policies and Suicide: A Review of the Literature. In Alcoholism, clinical and experimental research 40 (10), pp. 2043–2055. DOI: 10.1111/acer.13203.
Zarghami, Mehran (2012): Selection of Person of the Year from Public Health Perspective: Promotion of Mass Clusters of Copycat Self-immolation. In Iranian journal of psychiatry and behavioral sciences 6 (1), pp. 1–11.