Our central aim was to further understand suicide behaviors among Latinos by providing prevalence rates of lifetime suicidal ideation and attempts among a U.S. representative sample. We also examined variation across Latino ethnic subgroups as well as identify psychosocial and cultural correlates of suicidal behaviors. We found no Latino group difference in suicidal ideation. Our findings differ from previous reports in the literature that have found higher rates of suicide attempts among Puerto Ricans in local2
but not national samples. Our results show a lack of Latino group variation in suicide attempt rates potentially related to our use of a nationally representative sample which adjusts for differences across group distributions (for example including Puerto Ricans outside of the New York Metropolitan area), conducting interviews in English and Spanish, and our inclusion of an additional category of Other Latinos with rates approaching that of Puerto Ricans (further lowering differences in rates across Latino subgroups).
We were able to include a larger repertoire of psychiatric and social variables than those used in many previous studies on this subject. We considered variations in nativity, English proficiency, church attendance, and family relationships as potentially important sociocultural correlates of suicidality that could contribute to our understanding of differences in suicide rates across Latino subgroups. Because the Latino population is heterogeneous in terms of ethnicity, geography, acculturation, migration patterns, education, and socioeconomic status, we wanted to consider these differences in our examination of suicide behaviors. For example, U.S. born Latinos have been found to have a higher rate of mental health and substance abuse problems as compared to recent immigrant Latino populations25
and it has been hypothesized that increased exposure to the dominant U.S. culture (acculturation and time living in the U.S.) may be related to poorer mental health outcomes for Latinos over time.26, 27
Our findings do suggest that potentially different aspects of acculturation like current English proficiency, language spoken as a child, and parental US nativity may be risk factors for suicidal behaviors.
However, the mechanism by which acculturation is a potential risk factor for disorder and suicidality warrants further investigation. Oquendo and colleagues6
conducted a study including a mixed Latino and non-Latino white patient sample with depression, bipolar disorder or schizophrenia, and interviewed these patients regarding lifetime suicide acts along with the administration of the Reasons for Living Inventory (RFLI). They found that on the RFLI, Latinos scored significantly higher on subscales regarding responsibility to family and moral objections to suicide. Multivariate analyses suggested that although being Latino was independently associated with less suicidal ideation, less suicidal attempts held a stronger relationship to moral objections to suicide and using family support as a coping mechanism than to ethnicity. These results point to areas of culturally influenced coping strategies, especially use of family, and values that may contribute to variations in level of suicidal risk across different Latino ethnic populations with varying levels of acculturation.
Our results also evidenced that higher scores on family support were associated with decreased odds of lifetime suicidality while higher family cultural conflict was associated with an increased likelihood of both lifetime suicide ideation and attempts. Familism (family centeredness) may result in an important source of social support that may be protective for mental health but may also pose an area of important clinical intervention when there is family conflict.7–9
Accumulated stress in the family, family loss or instability and significant family conflict can all be factors linked to suicide attempts28
and a potentially critical issue for Latinos who are traditionally family-centered.29
It has been speculated that a shift in sociocultural frameworks and community supports as one integrates in the United States contributes to an increased prevalence of mental health disorders and suicidal behavior30
among immigrant Latinos and poses an ongoing risk for suicide among U.S. born Latinos. Since positive social supports is a known protective factor in regards to mental health and suicidal behavior,28, 31
the loss of such supports in the context of other stressors like acculturative distress, discrimination, may pose a meaningful stress to mental health for immigrant populations.
Religious participation, in contrast, has been found to play an important role in Latino culture even in the US and has been hypothesized to be influential in the lower rates of suicide among Latinos.23
Religious frameworks may define suicide as sinful and deny suicide as an option to cope with emotional distress. Our study examines church attendance and this may include individuals who experience the social obligation to attend and may not necessarily always reflect personally embraced religiosity and spirituality. However, churches can provide grounding in religious, cultural and civic values while nurturing social skills and encouraging constructive involvement in community and family life23
that may represent an additional and influential source of social support for many. It was not surprising that we found an inverse relationship between increasing church attendance and suicidality in our study.
Our results also need to be considered in gender and developmental contexts. Female gender appears to be one of the most significant risk factors for suicide attempts among Latinos in our study even among women without psychiatric disorder. The finding that Latina women are more likely to attempt suicide is consistent with findings for women in the general U.S. population.32
However, smaller studies and theoretical frameworks for research have suggested that the process of acculturation and related shifting family and gender roles may be an especially stressful situation for young women.7–9, 31
More rigid family structures with an emphasis on restrictive, authoritarian parenting may impair the capacity to respond flexibly to a changing cultural environment (e.g. during immigration).7, 8
Specific family-cultural issues may emerge in the differences between the traditional values, beliefs, and socialization practices of the family’s original culture versus those of the host culture, and between the rapidly acculturating and developing adolescent female and her less acculturated, more traditional parents. Changing perceptions of gender roles and family obligation can be an important and central family stressor in this context. Research on this topic primarily has focused on Puerto Rican girls but is becoming a recognized phenomenon across Latino ethnicity.7
In contrast, traditional Latino family values can also help support young women’s positive mental health by providing a healthy sense of cultural identity, a strong work ethic and orientation towards assisting family and others. These in turn can result in as sense of purpose, meaning, and belonging for the adolescent.33, 34
Our results suggest again the importance of examining the complexity of family dynamics in understanding suicide risk among young Latinas. Almost two-thirds of our sample reported that their attempted suicide occurred when they were under the age of 18 years. The patterns and history of suicidal behaviors that are reported by respondents reinforces the concern for the higher rate of suicide attempts reported nationally among Latina adolescent girls as compared to their non-Latina counterparts and the social and psychiatric mechanisms involved in these outcomes.7, 35
Interestingly, the sociocultural correlates for suicidal behaviors we have discussed thus far are similar across the presence or absence of diagnosable psychiatric disorder. Female gender remains the strongest correlate of suicide attempt regardless of diagnostic status. Family conflict is similarly correlated with suicide attempt in both Latinos with and without disorders, while church attendance is a significant protective factor for the no-disorder group. We might expect diagnosis to precede ideation and attempt in an orderly causal chain. However, our findings raise the question of whether suicidality as a behavioral phenomenon has important correlates that are independent of the presence of a full DSM-IV diagnosis. For example, risk for Latinas may be a function of conflicts within feminine role expectations.7–9, 36
An otherwise “healthy” individual might endanger self in response to chronic exposure to family conflict. In contrast to recent research advances linking brain function and processes to psychopathology37, 38
these findings suggest precursors to suicidality that are contextual rather than or in addition to biological factors. Alternatively, we should consider that the presence of distress in the study population may not always be defined by DSM-IV diagnostic criteria but embedded in a combination of psychosocial and interpersonal stressors.
We find it is important to frame these findings in a cultural context that considers the interaction of immigrant and cultural minority communities within the mainstream US culture. Specifically, we aim to examine some of the potentially different contributions of different facets of acculturation and social support on suicidality. For example, we find that being English proficient and speaking English as a child are both positively related to lifetime suicide attempt. These findings support those of other studies which have found that more acculturated individuals (of which English language is one important proxy) show higher rates of psychiatric disorder as compared to less acculturated recent immigrants.10, 25
Similarly, speaking English as a child has been associated with family disconnection and mental health risk as compared to bicultural and bilingual identity which has been associated with academic success and better mental health for Latinos and other immigrants.19, 33, 34
It may seem contradictory that we found higher educational attainment is negatively associated with suicide attempts since this variable usually is also associated with higher acculturation and English proficiency. It is important to remember that acculturation is not good or bad in and of itself but represents a more complex process.39
We can imagine a more educated individual becoming more acculturated (and being English proficient) yet simultaneously building personal resources, such as achieving a higher social position, which can be protective to mental health.40
Additionally, achieving a higher education does not necessarily mean letting go of a bicultural and/or bilingual identity.
Our results also provide evidence that meeting criteria for any DSM-IV psychiatric disorder is highly correlated with suicide ideation and attempts among Latinos, even when adjusting for age, gender and language/nativity. Therefore, the appropriate identification and diagnosis of these conditions continues to be an important component of treatment and prevention for Latinos in addition to addressing sociocultural risk factors. This is a serious challenge for a population which tends to have less access to mental health services than the general population due to lack of insurance, a shortage of culturally and linguistically trained service providers and stigma.27, 41
Limitations of study
Our results are limited by the cross-sectional nature of our data. Therefore, a discussion of causal relationships is not possible. In addition, we were only able to examine lifetime suicidal behaviors due to the very low 12-month prevalence of suicide attempts that limited our statistical analyses. Epidemiological data is limited in providing information and clarification about the richness of social context and culture, even though the NLAAS is particularly strong in this area. For example, a qualitative study of the sociocultural context of suicide attempts among Latina adolescent attempters is a next step in further examining the dynamic role of gender, family, social supports and culture in a particular Latino subgroup. Similarly, it is difficult to ascertain the meaning of suicidal attempt for respondents (e.g. are these gestures?). We are able to somewhat contextualize this in our finding that over 40% of respondents reported their attempts as having been serious and that they had not expected to survive.
Implications for prevention and treatment among Latinos
Social and cultural supports may be important factors influencing variations in suicide risk across Latino groups. Complete assessment and screening for suicidality should not be limited to depressive disorders but should be considered in the presence of dual or comorbid diagnoses. Our results also point to the importance of using a complete bio-psychosocial-cultural model in treating and considering suicidal risks among diverse groups of Latinos. Linear assimilation models continue to dominate public health research despite the availability of more complex acculturation theories that propose multidimensional frameworks, reciprocal interactions between the individual and the environment, and other acculturative processes. Our findings, regarding family conflict and the complexity of acculturation as a potentially dynamic and influential issue related to suicidal behaviors even in absence of full DSM-IV diagnoses, point to the importance of examining this area in clinical research and treatment with Latino subgroups.