in Hungary
6Andr´as Sz´ekely used data from Hungary to explore the suicidal risk consequences of the massive social transformation and fundamental changes in work and fam-ily life that have been occurring throughout Eastern Europe over the past several decades. Hungary has experienced not only growing socioeconomic inequity, with increasing socioeconomic deprivation over the past couple of decades, but also growing demoralization (i.e., increasing anomie, an especially challenging social condition given the Hungarian cultural propensity to uncertainty avoidance7), rising
6This section summarizes Andr´as Sz´ekely’s presentation at Tallinn, with some details from his submitted paper, which was co-authored by M´aria S. Kopp and Szilvia ´Ad´am.
7Geert Hoftsted (social scientist, 1928–) conducted an extensive analysis of cultural value data and identified five dimensions of culture: individualism, uncertainty avoidance, masculinity–femininity, power distance, and long-term orientation. For example, uncertainty avoidance is a measure of the ex-tent to which a culture feels comfortable or uncomfortable in unstructured situations (see www.geert-hofsted.com for more details)
unemployment and other work-related changes (e.g., increasing insecurity, decreas-ing perceived control in work, overwork, income inequities), and growdecreas-ing family instability at a time when the importance of family as a form of social support has been growing. (See Chapter 2 for a summary of major trends in Hungarian suicide rates, based on Katalin Kov´acs’s presentation).
As Sz´ekely summarized, suicide rates in Hungary gradually increased after 1920, spiking during WWII in 1944;8 they decreased after 1944 until 1956, pre-sumably because of the failure of the Hungarian Revolution, and then rose to an even higher level in the 1980s than in 1944. Toward the late 1980s, the rates began falling again, although there is no convincing explanation for the downward trend.
Despite growing societal disappointment in the early 1990s, suicide rates contin-ued to fall through 2004. The downward trend has been impressive and unique in comparison with most other East European nations. Still, Hungary’s suicide rate remains very high.
4.3.1 Two Surveys of the Hungarian Population: 1995 and 2002 Sz´ekely described the results of two surveys on psychosocial factors associated with suicidal behavior in Hungary. Separate surveys were conducted in 1995 and 2002, with 12,527 and 12,563 respondents, respectively. The 2002 data were col-lected as part of the Hungarostudy 2002 (Kopp & Kov´acs, 2006), a national cross-sectional survey of the Hungarian population. Respondents were categorized by gender, age, and place of residence. Respondents were asked approximately 600 questions on suicidal ideation, attempted suicide, suicide in the family, depres-sion, coping, social support, alcohol consumption, use of stimulants or sedatives, employment, and other demographic characteristics.
Demographic factors associated with suicidal behavior
Sz´ekely and colleagues identified several significant demographic predictors of sui-cidal behavior:
• Employment: In 1995, 21.7% of all respondents reported having had some suicidal thoughts, and 2.6% reported having attempted suicide. Unemployed and unskilled workers reported more suicidal ideation (37.6 and 30%, re-spectively) and attempted suicides (7.2 and 6.2%, rere-spectively) than people in other employment categories. In 2002, 10.34% of all respondents reported
8Following Sz´ekely’s presentation, a comment was made about the 1944 spike in suicide rates in Hungary and how the spike could be attributed to the very high suicide rates known to exist at the time in the country’s Jewish population. Sz´ekely commented on uncertainty around the reliability of suicide statistical data during that time because of the prevalence of firearms and the likelihood that many murders of Jewish individuals were reported as suicides.
having had some suicidal thoughts, and 1.85% reported having attempted sui-cide. The disabled, mothers on childcare leave, and the unemployed reported more suicidal thoughts (21.6, 14.8, and 14.7, respectively) and attempted suicides (5.0, 4.2, and 4.3, respectively) than people in other employment categories. It is not why clear why the percentage of unemployed workers reporting suicidal ideation decreased as much as it did between the two years.
• Education: Interestingly, the highest suicide attempt rates were not among the least-educated people in either year (i.e., primary or less in 1995; less than primary in 2002). Rather, in 1995, individuals with primary educa-tion plus another course of study reported the highest suicide attempt rates (6.52%). Likewise, in 2002, individuals with only primary education re-ported the highest rates (4.40%).
• Age: In both 1995 and 2002, the highest prevalence of suicide attempts was in the 50–59 age group (5.4% in 1995 and 4.0% in 2002).
• Marital status: Individuals who are either married but not living with their spouse, divorced, or cohabitating with a partner reported the highest sui-cide attempt rates both years. In 1995, 14.4% of married individuals not living with their spouse reported attempting suicide; in 2002, that figure fell to 6.34% but was still among the highest compared to other marital status groups. The percentage of divorced individuals reporting attempted suicide was 7.7 and 9.0 (living with a new partner and not living with a partner, re-spectively) in 1995 and 6.4 in 2002. The percentage of cohabitants reporting attempted suicide was 8.8 in 1995 and 6.7 in 2002. Sz´ekely commented on the significance of this last finding, given the increasing rate of cohabitation among unmarried partners in Hungary and elsewhere.
• Religious practice: With respect to religious practice (e.g., frequency of church attendance and other social behaviors), in 2002 people who said that they are believers but are practicing religion in their “own way” (as opposed to nonbelievers, individuals who attend church regularly, etc.) reported the highest suicide attempt rate (3.8%).
All types of suicidal behavior were associated with higher Beck Depression Inventory (BDI) scores, with individuals reporting no suicide attempts showing no significant depression (BDI scores of 7.8 and 7.7 in 1995 and 2002, respec-tively) and individuals reporting single or multiple suicide attempts showing signs of mild to severe depression (BDI scores ranged from 13.6 and 16.0 for individu-als reporting suicide attempts without medical attention in 1995 and 2002, respec-tively to 20.1 and 18.2 for individuals reporting multiple attempts in 1995 and 2002,
respectively—14.4 and 8.1% of individuals reporting either single or multiple at-tempts in 1995 and 2002, respectively, received BDI scores of over 25, which are considered severe depression).
Psychosocial factors most closely associated with suicidal behavior
Sz´ekely and colleagues conducted a multivariate regression analysis to identify which of the various psychosocial data collected were most closely associated with suicidal ideation and suicide attempts (Ad´am et al., in preparation). In 1995, the top six most predictive factors of suicidal ideation were: (1) eating, drinking, and smoking in difficult life situations; (2) drug use in difficult life situations; (3) Beck depressive symptomatology; (4) suicide in the family; (5) hostility in the family;
and (6) lack of social support in family. In 2002, the top six factors most predic-tive of suicidal ideation were: (1) Beck depressive symptomatology; (2) aggression in difficult life situations; (3) drug use in difficult life situations; (4) suicide at-tempts in the family; (5) lack of purpose in life; (6) drug abuse. Sz´ekely pointed out that, interestingly, religious behavior, specifically praying in difficult life situa-tions, ranked among the top psychosocial factors associated with suicidal ideation in both years.
With respect to suicide attempts, drug use in difficult life situations was iden-tified as the most significant predictor in both 1995 and 2002. The second most important risk factor was having had a suicide in the family (1995) or a suicide at-tempt in the family (2002). Sz´ekely pointed out that while Beck depressive symp-tomatology was identified as the third most important risk factor in 1995, it was not a significant one in 2002. That Beck depression scores did not show up as an important risk factor in 2002 does not necessarily mean that depression is not a predictor of suicide; rather, it underscores how critically important it is to consider all the other factors that do yield statistical significance and may underlie depres-sion (e.g., drug use in difficult life situations, suicide attempt in the family, alcohol and drug abuse, no purpose in life, lack of trust in others, no help from a partner or friend) when developing suicide prevention strategies. Also interesting was the fact that the inability to pursue an education appeared as a significant risk factor for suicide attempts in 1995.
Summary
In summary, the main demographic and psychosocial factors associated with suici-dal ideation and suicide attempts are:
• Inadaptive ways of coping (i.e., alcohol and drug abuse)
• Family problems (e.g., lack of help, history of suicide in the family)
• Little social support
• Hostility, anomie, no purpose in life
• Depression
• Low educational level, unemployment
4.3.2 The Need for Comparative Studies: Is Hungary’s Situation Unique?
Following Sz´ekely’s presentation, there was some agreement about the need for more collaborative research to determine which of the many risk factors identified as important in Hungary are important elsewhere. While collaborative research would be expensive, it might be something worthwhile for the WHO to consider when developing its international suicide prevention research program.
When asked following his presentation whether the Hungarian attitude toward suicide has changed over the years, Sz´ekely replied that, yes, it has changed. Still, the attitude toward suicide is not as negative as it is in other cultures. Hungary has a history of famous suicides, and many Hungarians continue to believe that there are situations where suicide is the only solution.