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The association between exposure to interpersonal violence and suicide among women: a systematic review Michael B. MacIsaac,1,2 Lyndal C. Bugeja,3 George A. Jelinek2

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lobally, suicide accounts for nearly one million deaths annually,1 with an estimated one suicide occurring every 40 seconds.2 Significantly, suicide is the second leading cause of death among 15-29 year olds around the world and is the third leading cause of death among those in the most economically productive age group (15-44 years).2,3 In Australia, more than 2,000 suicides occur annually and it is the leading cause of death for men and women under the age of 44 years.4

Demographic characteristics are important markers of suicide risk. In Australia, suicide rates among Aboriginal and Torres Strait Islander women under the age of 25 are five times that of non-Aboriginal and Torres Strait Islander women, while the rates for those aged 25 to 44 are three times higher.5 Similarly, an increased suicide rate is seen among the Māori population in New Zealand, with particularly high rates of suicide among Māori youth.6 Women living in rural or remote locations have a reported suicide rate of up to twice that of the general population.7 However, this relationship is complex8 and studies have produced varied findings.9,10 Early studies reported an increased suicide risk among women from culturally and linguistically diverse backgrounds,11,12 with much of the studied population made up of immigrants from the UK or European countries. However, this relationship is strongly influenced by the social and cultural norms of their country of birth.13-15 As such, this finding has not been replicated using recent data, with many recent migrants originating from Asian and Middle Eastern countries where the suicide rate is equal to

Abstract Objective: To review the association between exposure to interpersonal violence and suicide among women. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P), this review examined articles identified by using the key terms ‘interpersonal violence’, ‘suicide’ and ‘death’. Of 5,536 articles identified, 38 met the a priori inclusion criteria. These required that studies examined interpersonal violence, included women and completed suicide was a measured outcome. Results: Thirty-eight studies were identified. These examined suicides among women exposed to interpersonal violence as a victim (n=27) or perpetrator (n=14). A history of interpersonal violence was identified in 3.5-62.5% of female suicides, with many articles finding victims of abuse have an increased risk of death from suicide. Females perpetrating violence may also be at increased the risk of death from suicide. However, several papers have questioned these associations. Further, the contribution of mental illness to this association is unclear. Conclusions: Although the association between suicide and interpersonal violence requires further investigation, being a victim or perpetrator of violence appears to be associated with risk of suicide. Future research should focus on the impact that the type of violence, victimperpetrator relationship and proximity of violence has on the risk of death from suicide. Implications for Public Health: There may be significant opportunity for targeted suicide prevention strategies among women who have been victims or perpetrators of interpersonal violence. Key words: interpersonal violence, suicide, death, women or lower than that of the Australian-born population.13 One of the clearest risk factors for suicide and suicidal behaviour is mental illness, identified in more than 90% of people who die from suicide16-21 and most commonly involving affective or substance use disorders.20,21 Previous self-harm or suicide attempts have consistently been shown to be one of the strongest risk factors for later completed suicide, increasing suicide risk almost 40-fold.22 Suicide is commonly preceded by stressful life events, with factors such as

relationship breakdown, job loss, financial problems and a recent crisis playing a key role.23 While any one of these factors can increase the risk of suicide, suicide is rarely the consequence of one single cause but often the result of a combination of factors.24 Both childhood and adult exposure to interpersonal violence (IPV) are potential contributory factors to suicidal behaviour, mediated partially via mental health consequences but also as an independent risk factor.25 In Australia, 41% of adult women reported having experienced physical

1. St Vincent’s Hospital Melbourne, Victoria 2. The University of Melbourne, Victoria 3. Coroners Court of Victoria Correspondence to: Dr Michael B. MacIsaac, St Vincent’s Hospital Melbourne, 41 Victoria Pde, Fitzroy, Vic 3065; e-mail: [email protected] Submitted: January 2016; Revision requested: April 2016; Accepted: June 2016 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2016; Online; doi: 10.1111/1753-6405.12594

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Australian and New Zealand Journal of Public Health © 2016 Public Health Association of Australia

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MacIsaac, Bugeja and Jelinek

or sexual violence since the age of 15.26 Worldwide, it has been suggested that one in four women experience physical or sexual violence, or both, at some point in their lives.27 A World Health Organization (WHO) multicountry study found that 15-71% of women had experienced violence (physical, sexual or both) by an intimate partner at some point in their lives.28 Psychological violence was also highly prevalent, with 30-90% of women reporting one or more acts of controlling behaviours by an intimate partner. Child abuse is also a global phenomenon. Every year, 4-16% of children are physically abused, one in ten are neglected or psychologically abused and 5-30% are exposed to sexual abuse.29 In addition, up to 24% of children have witnessed intimate partner abuse (IPA),30 which can result in psychological harm or physical abuse from being caught up in the violence. The prevalence of elder abuse is less clear with a wide variation in reported rates,31 however it is estimated that 10% of elders experience some form of abuse.32 Some of the most severe and long-standing consequences of physical, psychological and sexual abuse relate to psychiatric illness. Many researchers have described the diverse impact that IPV can have on women’s mental health, including depression, anxiety, phobias, post-traumatic stress disorder (PTSD), and alcohol and drug abuse disorders.33 Psychological IPA is known to be as detrimental to women’s mental health as physical violence,34 highlighting the need to consider all modes of violence. One of the most extreme responses to IPV is suicidal behaviour.35-37 Women who were sexually abused show a 12 to 20fold increase in suicide attempts.38,39 An international systematic review published in 2012 concluded that all 37 studies examined found an association between IPA and suicidal ideations and attempts.36 Similarly, a meta-analysis found that child sexual abuse conferred a 150% increased risk of later suicidal behaviour.40 However, no systematic review to date has examined IPV and its relationship with completed suicide in women. This review aims to address this research gap.

Methods This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 Statement.41

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Search strategy A search of eight electronic databases covering the disciplines of public health, social science, medicine and criminology was performed. These comprised: Medline, PsycINFO, EMBASE, CINAHL, Scopus, Web of science, The Cochrane Library and Criminal Justice Abstracts. Databases were searched from their inception to March 2015. A list of key terms was formulated for the factors: ‘interpersonal violence’, ‘suicide’ and ‘death’. These terms were then searched as key words and mapped to Medical Subject Headings (MeSH) terms or equivalent subject headings and grouped together using Boolean operators. Any additional terms identified during individual database searches were added to create a master list, which was then searched in each database. This master list included common terminology such as ‘domestic violence’, ‘family violence’, ‘intimate partner violence’ and ‘child abuse’ (see Supplementary Table, available with the online version of this article). Results were then exported into Endnote X7 software and duplicates removed. Each entry was screened for eligibility against the pre-defined inclusion criteria, initially by title and abstract and then by full text if there was uncertainty about appropriateness. One researcher (MM) performed this task, however when uncertainty arose, other researchers (LB and GJ) were consulted and eligibility was determined via a consensus decision. The references of included articles were examined to identify additional relevant studies.

Definitions IPV was defined in accordance with the WHO, as the intentional use of physical force or power, threatened or actual against another person that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation. This inclusive definition makes distinctions based on both mode of violence (physical, sexual, psychological and deprivation) and victim-perpetrator relationship (family and intimate partner violence, including child maltreatment, intimate partner abuse and elder abuse; and community violence, including acquaintance and stranger relationships).1 While the definition of IPV varies both between and within countries, we chose to apply the WHO definition as it allowed the most inclusive and universal description of IPV to be employed.

Suicide was defined in accordance with the Centre for Disease Control and Prevention (USA), as death caused by self-directed injurious behaviour with any intent to die as a result of the behaviour.42

Inclusion criteria Studies were eligible for inclusion if they met all of the following criteria: i) published in English language; ii) women were included; iii) women were reported to have been exposed to IPV at any point in their lifetime (as a victim or perpetrator); iv) suicide was an outcome measures and v) the study examined exposure to IPV among women who died from suicide. Studies were excluded if they did not explicitly define the behaviours comprising IPV (e.g. only reported interpersonal conflict/ problem) or if results were not reported separately for men and women. Studies examining solely ‘homicide-suicide’ were also excluded. This is reported to be a phenomenon distinct from suicide alone, differing in socio-demographic and event characteristics as well as the motivations and psychology triggering such events.43-46

Data extraction The full text of included articles was reviewed and the following information was extracted and recorded in a Microsoft Excel spreadsheet: author; date of publication; study location; study period; study design; number of participants; population studied; modes of violence studied; relationship types studied; measure of suicide; measure of violence; proximity of violence exposure to suicide; salient findings and study strengths/ limitations. The quality of cohort and case-control studies was assessed using the Newcastle Ottawa Scale (NOS).47 An adapted version of this scale, previously used in public health research by Herzog et al.48 was employed for the assessment of retrospective audits, crosssectional and psychological autopsy studies.

Data analysis Articles were stratified according to the direction of violence (victim or perpetrator) studied and descriptive analyses were conducted, examining mode of IPV, victimperpetrator relationship, proximity of IPV to the act of suicide and the association between violence and suicide.


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Interpersonal violence and suicide among women

Results Study selection The combined searches yielded 12,301 results. From these, 6,765 duplicates were removed. Based on the inclusion criteria, an initial examination of the titles and abstracts excluded 5,216 articles. The full text of the remaining 320 articles was reviewed, 38 of which met the eligibility criteria (Figure 1).

Study characteristics All studies included were published in English. Dates of publication ranged from 1981 to 2014. The majority of studies (n=10) were conducted in the USA. The other studies were in India (nine), Sweden (five), Denmark (two), Australia (two), Papua New Guinea (two) and one each in the United Kingdom, Canada, Bangladesh, Sri Lanka, Finland, Germany, Turkey, and the countries and dependent territories of the Americas. Almost 30% (n=11) of studies were retrospective audits in design. The remaining studies varied in design and included cohort studies (seven), case reports (seven), casecontrol studies (six), cross-sectional studies (four), a psychological autopsy study and two articles examined news reports identified from either print newspapers or a Google news search. Eighteen of the 38 studies focused solely on women, with two reporting only on women who were either pregnant or of reproductive age. The remaining 20 studies also included men, however results were reported separately for men and women (Table 1). Four studies sourced their data from the Violent Death Reporting System (VDRS) in the US (two including data from 16 US states, one from 17 states and one from only New Mexico).

Records identified through database search 12,301

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# duplicate records removed 6,765

# of records screened 5,536

# of records excluded from tittle and abstract 5,216*

# full-text articles assessed for eligibility 320 # full-text articles excluded, with reasons: Not original, descriptive research 59 Abstracts, theses, books, grey literature 14 Did not study exposure to interpersonal violence 74 Did not study completed suicide 29 Did not study females 20

Twenty-seven of the 38 studies examined suicide among female victims of IPV. Twentyfour of these focused solely on victims, while three examined both victims and perpetrators of violence.

The mode of violence was explicitly stated in 17 of 27 studies. Among the studies that defined the modalities examined, physical abuse was the most commonly studied (n=15).49-63 Psychological or emotional abuse was the next most studied modality,

The victim–perpetrator relationship was described 18 of 27 studies. The most frequently studied relationship was between intimate partners (n=16). All six case reports focused primarily on IPA,55-57,59,60,67 while four retrospective audits,52,61,68,69 three crosssectional,53,70,71 two case-control49,72 and one news report based study63 also examined suicide in women exposed to IPA. The next most commonly studied relationship was violence experienced from other family members (n=8). Seven of these examined violence perpetrated by in-laws,49,56,63,66-68,71 and one included abuse within the

Figure 1: PRISMA flow diagram for identification, screening, eligibility and included articles.

Study findings – suicide among women who were victims of interpersonal violence

Mode of Violence

Victim–perpetrator relationship

with seven studies reporting on this type of violence.49-53,57,63 Sexual abuse was studied in six of the identified articles,50,53,59,62,64,65 neglect in three50,63,66 and verbal abuse in two.49,51 In addition, one study incorporated witnessing violence in the home into their definition of the studied outcome ‘environmental trauma’.50 More studies examined a single mode of violence (n=9) than incorporated multiple modalities (n=8). Seven studies focused solely on physical violence,54-58,60,61 while an additional two exclusively examined sexual abuse.64,65 Only two studies50,53 included a broad definition of violence, including most WHO defined modalities of IPV.

Did not disaggregate results by gender 37 Did not study relationship between interpersonal violence and suicide 25 Solely examined homicide-suicide 27 Did not specify direction of violence 1 Studies included in review 38** Figure 1: PRISMA diagram for suicide; identification, screening, eligibility included articles. *Did not study interpersonalflow violence or completed did not describe the relationship betweenand interpersonal violence and suicide; did not include females; *Did not study interpersonal violence or completed suicide; did not describe the relationship between interpersonal violence and not original research. suicide; did not include females; not original research. **Four identified by bibliographic review review **Fourarticles articles identified by bibliographic


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Table 1: Description of studies examining interpersonal violence and suicide in women. Factors defined

Experience of violence

Mode of violence

Relationships

Cutajar et al.64

1964-2008

Aus; Vic

Co

18yrs

>18yrs

F only

174

Victims only



-

RMR of suicide among victims of violence 17x higher than non-exposed comparators

6

Bailey et al.72

1987-1990

USA; TN, WA

CC

Lifetime

>14yrs

F only

123

Victims only

-

 -

DV significantly associated with death from suicide (OR 3.5) in univariate analysis, however not in multivariate analysis

6

Ahmed et al.49

1982-1998

Bangladesh; Matalab

CC

Lifetime

15-44yrs

F only

101

Victims only



 -

Prior ill treatment by husband and/or in-laws present in 30.9% of suicides aged 15-44yrs

4

Runyan et al.70

1989-1993

USA; NC

Cs

Lifetime

>15yrs

F only

882

Victims only

-

-

3.5% suicides had a history of DV; 0.2% a history of child abuse

4

Tapse et al.66

2008-2010

India; KA

Cs

-

18-30yrs

F only

72

Victims only

-

 -

Ill-treatment by in-laws in 26.4% of suicides; rash/negligent behaviour by husband in 15.3% suicides

4

Parsons et al.53

1992-1994

USA; NC

Cs

-

Childbearing age

F only

5

Victims only



 -

40% of suicides were known or suspected victims of DV prior to their death from suicide

3

Gupta el al.71

2008-2010

India; UP

Cs

-

All ages

M+F

43

Victims only

-

 -

51.2% of suicides had experienced torture by husband and/or in-laws

3

Babu et al.61

2007

India; 15 states

RA

-

15-49yrs

F only

3,148

Victims only



 -

No significant relationship between exposure to physical spousal violence and dowry-related suicide

7

Pritchard et al.65

1988-1993

UK; Wessex

RA

(‘Child’)

>15yrs

M+F

260

Victims only



 -

Suicide rate among CSA victims 2.4x higher than general population

5

Olson et al.52

1990-1994

USA; NM

RA

-

>14yrs

F only

313

Victims only



 -

IPA identified in 5.1% of deaths from suicide

5

Singh et al.62

1979-2005

USA; NM

RA

Lifetime

18yrs

M+F

8

Victims only



 -

62.5% of suicides had a history of childhood trauma, including physical, sexual or emotional abuse, neglect or witnessing family violence

3

Badiye et al.54

2009-2013

India; MH

RA

-

All ages

M+F

659

Victims only



-

0 cases of physical abuse prior to death from suicide identified

3

Nuchhi et al.68

2009-2010

India; KA

RA

-

>18yrs

F only

23

Victims only



 -

Among dowry-related deaths, 48.5% abused by husband, 37.1% abused by both husband/ relation, 8.6% abused by relation of husband

3

Mohanty et al.75

1993-2003

India; KA

RA

-

11-60yrs

M+F

31

Victims only

-

-

-

Dowry-related abuse the commonest reason identified for suicide (30.1% cases)

2

Srabstein51

2011-2012

The Americas

NR

Lifetime

5-19yrs

M+F

6

Victims only



-

-

6 bullying-related suicide cases in 6 Western countries

-

Prasad et al.63

1981-1988

India

NR

-

-

F only

40

Victims only



 -

40 cases of dowry-related suicide described

-

Demirci et al.

-

Turkey

CR

-

39

M+F

1

Victims only



 

Suicide following physical abuse from husband

-

Gargi et al.

2009

India; PB

CR

-

25/26

F only

1

Victims only



 -


-

Counts57

1966-1986

PNG; WBK

CR

-

-

F only

5

Victims only



 -

Suicide following physical, verbal or psychological abuse from husband

-

Seeman59

1995-2005

Canada; ON

CR

-

33-50yrs

F only

5

Victims only



 -

Suicide following physical abuse from husband or sexual abuse from father

-

Waters67

Early 1990s

India; MH

CR

-

-

F only

3

Victims only

-

 -

Suicide following physical and psychological abuse from husband/in-laws.

-

Johnson60

1977-1978

PNG

CR

-

20-49yrs

F only

4

Victims only



 -


-

Country, state/ province

Study Design

Key finding Proximity

Study period

Study

Number of female suicides

Gender

Quality of study

Age of suicide

Sample description

Age of exposure to violence

Study population

Studies Examining Victims of IPV

55

56

4

-

-

-

-


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Table 1 cont.: Description of studies examining interpersonal violence and suicide in women. Factors defined Relationships

Proximity

Sweden

Co

1519yrs

20-34yrs

M+F

393

Perpetrators only



-

-

Fully adjusted model found violent offenders had an increased rate of suicide (RR = 4.2) compared to non-convicted women.

8

Webb et al.79

1973-2004

Sweden

Co

>15yrs

>15yrs

M+F

244

Perpetrators only



-

-

No significant elevated risk of suicide among violent offenders compared to non-violent offenders (RR = 0.87)

5

Fazel et al.76

1972-2009

Sweden

Co

>15yrs

>15yrs

M+F

145

Perpetrators only



-

-

Violent offences not associated with increased suicide risk among schizophrenic patients or their unaffected siblings compared to matched non-schizophrenic controls

4

Kariminia et al.83

1973-2004

Aus; NSW

Co

>17yrs

18-86yrs

M+F

49

Perpetrators only



-

-

No greater increased suicide risk for violent offenders compared to non-violent offenders

3

Jokinen et al.81

1971-2002

Sweden

Co

-

-

M+F

2

Perpetrators only



-

-

12.5% of violent offenders died from suicide within the follow up period

3

Putkonen et al.82

1982-1999

Finland

Co

-

19-83yrs

F only

6

Perpetrators only



-

-

Compared to the general population, the suicide rate among violent offenders was significantly elevated (SMR 424.8%)

2

Webb et al.77

1981-2006

Denmark

CC

>15yrs

>15yrs

M+F

9,156

Perpetrators only



-

-

Violent offenders at more than 8x higher risk of suicide than general population (OR 8.40). This risk was retained in multivariate analysis (OR 2.08)

7

Webb et al.80

1981-2006

Denmark

CC

>15yrs

>15yrs

M+F

9,156

Perpetrators only



-

-

Same data and results as above study

7

Conner et al.84

1993

USA

CC

12 months prior

20-64yrs

M+F

236

Perpetrators only



-



Perpetrators of violence in the past year at 8x higher risk of suicide (OR 8.0) compared to those who did not perpetrate violence

6

Samaraweera et al.86

-

Sri Lanka

PAS

Lifetime

>15yrs

M+F

8

Perpetrators only

-

 -

37.5% had perpetrated IPA prior to suicide

5

Vennemann et al.85

-

Germany

CR

-

-

F only

1

Perpetrators only



 -

Suicide following perpetrating physical abuse against daughter

-

0.9% had been a victim of IPV in month prior to suicide; 1.8% had perpetrated IPV in month prior to suicide

5

Country, state/ province

Study Design

Experience of violence

1972-2006

Study period

Number of female suicides

Bjorkenstam et al.78

Study

Age of exposure to violence

Mode of violence

Quality of study

Gender

Sample description

Age of suicide

Study population

Key finding

Studies Examining Perpetrators of IPV

Studies Examining Both Victims and Perpetrators of IPV Styka et al.73

2005-2006

USA; NM

RA

Month prior

>18yrs

M+F

113

Victims and Perpetrators

-

-

Ortega et al.69

2003-2007

USA; 16 states

RA

Month prior

15-44yrs

F only

3,784


-

 

2% victims or perpetrators of IPV in month prior to suicide

3

Karch et al.74

2005-2008

USA; 16 states

RA

Month prior

10-17yrs

M+F

242


-

-

3.7% had been a victim of IPV in month prior to suicide; 2.5% had perpetrated IPV in month prior to suicide

3





General: , reported in article; -, not specified/defined State/Province: Vic, Victoria; TN, Tennessee; WA, Washington; NC, North Carolina; NM, New Mexico; UP, Uttar Pradesh; KA, Karnataka; MH, Maharashtra; PB, Punjab; WBK, West New Britain; ON, Ontario; PNG, Paua New Guinea Design: Co, cohort; CC, case control; RA, retrospective audit Cs, cross-sectional; NR, news report study; CR, case report; PAS, psychological autopsy study Gender: M, male; F, female Key finding: CSA, child sexual abuse; IPA, intimate partner abuse; DV, domestic violence; RMR, relative mortality risk; OR, odds ratio; RR, rate ratio; SMR, standardised mortality ratio Quality of study: Quality assessment was conducted using the Newcastle-Ottawa Scale (NOS). A maximum score of 9 is possible for each study design. Cohort studies were evaluated on their selection of exposed and non-exposed cohorts, ascertainment of exposure, whether outcome present at start of study, comparability of cohort, assessment of outcome, duration and adequacy of follow up. Case control studies were evaluated on the selection and adequacy of definitions for cases and controls, representativeness of cases, comparability between cases and controls, ascertainment of outcome exposure amongst cases and controls and the description of non-responders. An adapted NOS was used to evaluate retrospective audits, cross-sectional and psychological autopsy studies on the representativeness of sample, sample size, number and description of non-responders, ascertainment of exposure, comparability, assessment of the outcome and statistical methodology. News and case report studies could not be evaluated.

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parent-child relationship.59 Suicide in childhood victims of violence was studied in five articles,50,59,64,65,70 however only one of these specified the exact relationship of the perpetrator to the childhood victim.59 One study explored the impact of bullying on the risk of suicide,51 however, did not specify the relationships examined.

of IPV and suicide. Eleven of these focused solely on perpetrators of violence, while three included victims as well as perpetrators. Eight articles76-83 studied criminal offenders, using violent or sexual crimes as a way to identify perpetrators of IPV. Two articles identified from a research group in Denmark.77,80 reported the same results from the same dataset.

Proximity of exposure to interpersonal violence and suicide

Mode of violence

The role that the temporal proximity of exposure to IPV plays in suicide risk was not routinely examined. Five studies55,56,69,73,74 defined a time period within which IPV was experienced, however none examined the impact this had on suicide risk.

Of the 11 studies investigating exclusively the association between perpetrating violence and suicide, 10 defined the mode of violence studied.76-85 This is likely the result of more complete data sources, with many using registries of criminal offences (or equivalent databases) to define their population of violence perpetrators.

Presence and strength of association All but two studies reviewed reported an association between being a victim of IPV and death by suicide among women. The reported lifetime prevalence of exposure to violence in women dying from suicide ranged from 3.5%-62.5%.50,70 One high-quality study found that any exposure to violence may increase the risk of death from suicide by up to 17-fold, compared to women not exposed to violence.58 Similarly, an Australian study reported that women who were victims of childhood sexual abuse might be at up to 40 times higher risk of dying from suicide.64 Ill-treatment (including physical, emotional, psychological or verbal abuse) or oppression by a husband contributed to almost half of suicides among women in one area of Bangladesh.49 Many additional studies from India highlighted the issue of dowry-related violence, from a partner or in-laws, with three finding it to be the most common reason for women dying from suicide.66,71,75 However, not all the literature was consistent. Bailey et al.72 found that when accounting for confounding variables such as mental illness, the association between experiencing IPV and suicide was not significant. In fact, over 85% of suicide cases with a history of domestic violence had a history of depression or other mental illness. Similarly, in examining dowry-related suicides, Babu et al.61 found no significant relationship between physical spousal violence and female suicide.

Study findings – suicide among women who were perpetrators of interpersonal violence Fewer studies (n=14) investigated the association between women as perpetrators

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The most frequent mode of violence was physical, included in all studies that defined modality. Two articles studying ‘violent offences’ explicitly outlined the types of violence included,77,80 while another two focused solely on those previously convicted of homicide.81,82 The next most commonly reported modality was sexual offences, included in seven of ten articles,76-80,83,86 psychological abuse was examined in four studies76,78,79,84 and one case study reported maltreatment and neglect of a child in a case of Munchausen syndrome by proxy, in which the mother (perpetrator) later killed herself.85 All studies but two incorporated at least two violence modalities, with Jokinen et al.81 and Putkonen et al.82 focusing solely on those previously convicted of homicide. Three articles examined only physical and sexual abuse,77,80,83 while three studied each of physical, sexual and psychological violence.76,78,79

Victim–perpetrator relationship The victim–perpetrator relationship was only clear in a small number of studies (n=3). All of these examined violence within an intimate or familial relationship. One was a case report85 depicting a female perpetrating abuse against her child, while the other two focused primarily on intimate partner relationships.69,86

Proximity of exposure to interpersonal violence and suicide More than half the studies did not report on the temporal proximity of violence to death by suicide, and of those that did, none examined the impact this had on the final

outcome. Conner et al.84 reported on different forms of violence occurring within the 12 months prior to suicide, while others69,73,74 reported on violence perpetrated within the month prior to suicide from the Violent Death Reporting System in the US.

Presence and strength of association There were conflicting findings regarding the impact that perpetrating violence had on suicide risk. Conner et al.84 showed that women who perpetrated violence within the past year were eight times more likely to die from suicide. Further case-control studies showed that women convicted of violent offences had a three to 45 times increased risk of suicide, depending on the number of violent offences of which they had been convicted.77,78,80 This elevated risk of suicide remained significant after confounding variables were taken into account in multivariate regression analyses. These studies primarily reported associations regarding physical violence, as no studies had large enough sample sizes of female sexual offenders to study this separately. Conversely, two recent studies of women perpetrating violence showed no significant elevation of suicide risk in a cohort of patients with schizophrenia, or in their unaffected siblings.76,79 Additionally, Kariminia et al.83 found that among prisoners, offence type (i.e. violent vs non-violent) was not associated with an increased suicide risk.

Discussion Summary of results This systematic review examined 38 published studies to characterise the presence, nature and impact of IPV on suicide among women. The prevalence of exposure to IPV among women who die from suicide is difficult to determine accurately due to variations in and absence of uniform definitions. The term interpersonal violence is extremely broad and varies between countries and cultures, and if not clearly defined, can easily lead to misinterpretation. Terms identified in this review included ‘intimate partner violence’, ‘domestic violence’ and ‘child abuse’. However, it was rarely clear what types of violence this encompassed. Two studies73,74 did report on ‘interpersonal violence’, however went on to use IPA as an interchangeable synonym, creating confusion. In addition, the victim-perpetrator relationship was not


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systematically categorised and definitions rarely provided. The term ‘domestic violence’ while often referring to IPA, can be extended to include other household relationships and therefore needs to be defined to avoid misinterpretation. All studies that divided familial violence into categories focused on dowry-related suicides. One49 examined violence perpetrated by the husband and/or in-laws separately to abuse by parents, siblings or other relatives, while the others63,66,68,71 only studied husband and in-law relationships independently. The influence of the temporal proximity of exposure to IPV on suicide risk among women has not been studied at all. Only six of 38 studies included any measure of proximity55,56,69,73,74,84 and all of these limited themselves to the 12-months prior to death. While this defines the period within which a woman was exposed to violence, it does not provide any evidence of the impact this had on suicide risk. Further, reporting violence in this way ignores a significant number of women who may have been exposed to IPV prior to the defined period.

these countries.66,71,75 Experiencing IPV in other settings around the world may also contribute to a woman’s risk of death from suicide, however this relationship is unclear and significant differences in reported prevalence rates exist, ranging from 3.562.5%.50,70 The reported community rates of exposure to IPV are in fact similar to these reported prevalence rates among women dying from suicide.26,28 Further, those articles that examined confounding variables have suggested that any reported association may be due to confounding mental illness rather than mediated directly by the impact of violence.72 Most studies examining perpetrators of IPV have shown an increased suicide risk among criminal offenders,77,80,84 with the risk increasing in proportion to the number of violent crimes committed.78 However, Kariminia et al.83 suggest this increased mortality among prisoners may be independent of offence type. The finding of increased suicide risk among violence offenders has also not been replicated in schizophrenic patients.76,79 This may be due to the already increased risk of violent death or early mortality in schizophrenics, mitigating the impact perpetrating violence has on suicide risk.88 Additionally, the majority of studies examining perpetrators of violence focused solely on criminal offenders. This is likely to include a higher percentage of more severe crimes (conferring higher risk of suicide) and ignores the many violent offences that occur but are not reported.

Case series published by Counts57 and Johnson60 from Papua New Guinea in the 1980s were some of the first publications highlighting the impact that abuse and torture can have on women’s mental health. The risk of death from suicide has since been reported to be up to 17 times higher for women exposed to violence than nonexposed controls.58 Experiencing childhood sexual abuse can increase the risk of suicide up to 40-fold.64 Familial violence (abuse from husbands and/ or in-laws) has been suggested to contribute to one-quarter to a half of female suicides in some settings,49,66,71,75 however much of this data comes from countries in which dowryrelated violence is a major issue and therefore is likely not applicable to cultures where this behaviour is non-existent. Dowry occurs in countries such as India, Pakistan, Bangladesh and Iran and refers to a cultural process whereby after a marriage, a husband’s family takes the newly wed bride into their home and in exchange, demands a form of financial or material compensation from the bride’s family.87 When dowry demands are not met, the husband and in-laws subject the woman to ruthless physical and mental harassment. Young brides may view suicide as the only escape from this brutality and it is reported to be the most common motive for young women to take their own lives in

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Strengths and limitations of studies The majority of studies examined in this review were retrospective audits or crosssectional in nature. Interpretation of these studies is limited as causality cannot be concluded. Parsons et al.53 only reported five suicides, with insufficient statistical power to draw definitive conclusions. Similarly, Badiye et al.54 identified no cases of physical abuse in the history of 659 women who died by suicide. From what is known about the prevalence of physical abuse among women, especially in India where dowry-related violence exists, questions are raised about their data collection or a potential reporting bias. Only six case-control studies were identified, which is surprising as these are typically employed in studies of less common outcomes.89 Suicide falls into this category. Further, fewer than half of these studies

accounted for confounding variables with multivariate regression analysis. While the association of IPV with suicide was retained for women who perpetrate violence in studies controlling for confounding variables, this was not always the case for studies examining women who were victims of violence. The fact that many studies did not account for confounding factors, in particular mental health status is a significant limitation of this body of literature. Psychological autopsy studies have been one of the most valuable study designs for providing detailed information about life events and circumstances surrounding suicide.90 However when studying exposure to violence, they have been poorly utilised with only one study employing this protocol. Few studies thus far have included a broad definition of interpersonal violence, incorporating all modes of violence as defined by the WHO. Of those that have, none have disaggregated results to comment on the relative contribution to risk of suicide that each mode of violence plays or the impact of the relationship within which the violence is experienced. Aside from IPA and in-laws (in dowry settings), there are no other well-defined relationships examined in the literature. Child abuse is often studied, but rarely is the relationship to the perpetrator explicitly noted. Further, the impact that proximity of exposure to IPV has on suicide risk among women has not been studied.

Strengths and limitations of the systematic review To date, this is the only systematic review of the association between IPV and completed suicide among women. One of the key strengths of this study was the all-encompassing definition of IPV applied, allowing studies examining any form of violence to be included. In addition, this review did not focus solely on victims of violence, but also endeavoured to explore the relationship between perpetrating violence and suicide. Further, this review did not exclude any articles based on study design or quality, allowing us to assess a wide range of literature. A limitation of this review was the inclusion criteria applied. Studies solely examining homicide-suicide were excluded to avoid confounding our results, as this phenomenon overwhelmingly involves males and the motivations surrounding the event are more


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closely aligned with homicide psychology than that of suicide. Further, we excluded studies that did not explicitly disaggregate results by gender, as the impact of violence on suicide risk for females alone could not be examined. This review also limited itself to papers published in the English language and we did not undertake duplicate quality assessment, leading to the potential for reporting bias. Lastly, much of the association between IPV and suicide in women might be mediated by the mental health consequences of experiencing violence, which are well documented.

Conclusion This review has highlighted the impact of IPV on women’s health and mortality through suicide. While several forms of IPV, in particular intimate partner and child/ adolescent abuse may be risk factors for suicide, this association remains unclear and requires further investigation. Few studies to date have been of sufficient size or comprise sufficiently detailed data to examine the influence of IPV on suicide and the factors that mediate this relationship. No studies have been able to incorporate a broad definition of both the relationships within which violence exposure occurs and the type of abuse experienced. This is a major deficiency in the current literature. To better enable targeted suicide prevention strategies, future research requires uniform definitions regarding types of violence and relationships between victim and perpetrator. This will aid in confirming and quantifying the association between IPV and suicide. Investigating the different aspects of violence, namely modality, victim-perpetrator relationship and proximity, and the relative contribution that each has on suicide risk will be key to understanding this phenomenon. This knowledge will inform and assist the development of much-needed suicide prevention strategies, targeting women who have been exposed to IPV and may be at high risk of death from suicide.

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Supporting Information Additional supporting information may be found in the online version of this article: Supplementary Table 1: Master list of key words identified for each of the key terms and subsequently searched in each database.


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