6
Society and Culture

Suicide carries a social and moral meaning in all societies. At both the individual and population levels, the suicide rate has long been understood to correlate with cultural, social, political, and economic forces (Giddens, 1964). Suicide is not everywhere linked with pathology but represents a culturally recognized solution to certain situations. As such, understanding suicide and attempting risk prevention requires an understanding of how suicide varies with these forces and how it relates to individual, group and contextual experiences.

Society and culture play an enormous role in dictating how people respond to and view mental health and suicide. Culture influences the way in which we define and experience mental health and mental illness, our ability to access care and the nature of the care we seek, the quality of the interaction between provider and patient in the health care system, and our response to intervention and treatment. This has important implications for treating individuals belonging to different racial, ethnic and cultural groups in the United States, as discussed in detail in the Surgeon General’s Report, Mental Health: Culture, Race, and Ethnicity (US DHHS, 2001). Cultural variables have a far-ranging impact on suicide. They shape risk and protective factors as well as the availability and types of treatment that might intervene to lessen suicide. This chapter describes a framework for thinking about the continuum of cultural influences on suicide. Next, it explores the roles of the individual, of geographical location, of society, and of historical perspective on the social factors that impact the risk of suicide. Finally, some of the barriers to a full understanding of social and cultural forces on suicide are described.



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Reducing Suicide: A National Imperative 6 Society and Culture Suicide carries a social and moral meaning in all societies. At both the individual and population levels, the suicide rate has long been understood to correlate with cultural, social, political, and economic forces (Giddens, 1964). Suicide is not everywhere linked with pathology but represents a culturally recognized solution to certain situations. As such, understanding suicide and attempting risk prevention requires an understanding of how suicide varies with these forces and how it relates to individual, group and contextual experiences. Society and culture play an enormous role in dictating how people respond to and view mental health and suicide. Culture influences the way in which we define and experience mental health and mental illness, our ability to access care and the nature of the care we seek, the quality of the interaction between provider and patient in the health care system, and our response to intervention and treatment. This has important implications for treating individuals belonging to different racial, ethnic and cultural groups in the United States, as discussed in detail in the Surgeon General’s Report, Mental Health: Culture, Race, and Ethnicity (US DHHS, 2001). Cultural variables have a far-ranging impact on suicide. They shape risk and protective factors as well as the availability and types of treatment that might intervene to lessen suicide. This chapter describes a framework for thinking about the continuum of cultural influences on suicide. Next, it explores the roles of the individual, of geographical location, of society, and of historical perspective on the social factors that impact the risk of suicide. Finally, some of the barriers to a full understanding of social and cultural forces on suicide are described.

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Reducing Suicide: A National Imperative FRAMEWORK: A SOCIAL SAFETY NET Human connections through informal and formal organizations and the tenor of social change are sources of both distressing and liberating events. They also are the building blocks of a “safety net” that can push individuals toward or pull them away from suicide as a “solution” to their problems. A description of this social safety net originated early in the history of suicide research and evolved over time (Durkheim, 1897/ 1951). As illustrated in Figure 6-1, individuals in crises often find themselves in social and cultural situations where the both the integration (i.e., love, comfort, caring, feelings of belonging) and regulation (i.e., obligations, duties, responsibilities, oversight) are moderate in level. They would be near the bottom of the net where the bonds to others are able to “catch” the individual in crises, protecting them from suicide. However, as a social or cultural group becomes too loosely bound together on either dimension, individuals facing crises are not provided with bonds of either concern or obligation, are not provided with sufficient support to deter the resort to suicide as a solution. These circumstances are presented at the front and left-hand side of the social safety net in Figure 6-1. For example, historically, in the Austro-Hungarian Empire in the nineteenth century, suicide rates have been reported to be correlated with low levels of social integration (Ausenda et al., 1991). In contemporary times, individuals in the United Kingdom under age 35 who completed suicide FIGURE 6-1 Networks and the Durkheimian Theory of Suicide. SOURCE: Pescosolido and Levy, 2002. Copyright © 2002. Reprinted with permission from Elsevier Science.

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Reducing Suicide: A National Imperative were found to be more “rootless” and have withdrawn socially compared to case-controls (Appleby et al., 1999; see also Trout, 1980, on the general role of social isolation on suicide). Bille-Brahe (1987) attributes the differences between Norway and Denmark’s suicide rates to be due to difference in social integration; and in Norway, where the level of integration among young men was reported to be in decline, suicide rates among this groups are increasing. Over time, the doubling of the Irish suicide rate since 1945 appears to be directly related to lower levels of regulation and integration (Swanwick and Clare, 1997). However, social and cultural groups can also be repressive, stifling, and conducive to suicide. In circumstances where the social group demands 100 percent loyalty and commitment, individuals lose their capacity to decide on options to crises. In these “greedy groups” as Coser and Coser (1979) called them, individuals are called on to demonstrate their commitment to the group and its causes by handing over the power of life and death to the group’s needs (See Box 6-1; see right and back side of the social safety net). Under these circumstances, the social network ties of BOX 6-1 Cases of “Altruistic” or “Fatalistic” Suicide: September 11, 2001, Jonestown, and the Branch Davidians There have been a number of recorded instances of apparently ideologically motivated suicides best explained by understanding the power of the group beliefs over individuals. The terrorists who willingly gave their lives to promote the anti-American cause of the Al-Qaeda terrorist organization; the over 700 individuals in Jonestown, Guyana, who drank cyanide-laced Kool-Aid; and the members of David Koresh’s religious group who allegedly set fire to their compound in the face of the federal government’s attempt to enter, all represent cases where individuals were expected to give up their lives for the group and its cause. In some cases, there is debate whether these are situations where the attachment to the group was so strong that individuals had handed over their lives willingly (over-integration) or whether there was coercion (over-regulation) involved. Nevertheless, there is no evidence, for example, that the religious extremists who become “martyrs” have a mental illness. Palestinian and Israeli psychiatrists and psychologists who have interviewed “suicide bombers” (recruited or foiled) are impressed with their acceptance of suicide as a highly positive status, a moral status that is elevated by their commitment to a radical religious goal. These are all seen as suicides explained not by individual level decisions or problems but by the power of the social and cultural groups to which individuals belonged (Black, 1990; Maris, 1997; Pescosolido, 1994).

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Reducing Suicide: A National Imperative integration and regulation are so dense that the safety net closes up and forms a wall which shatters rather than supports (Pescosolido, 1994). Social and cultural forces that are this strong in their contribution to suicide must be understood fully and considered in risk prevention. SOCIETY AND CULTURE IN SUICIDE The social and cultural factors correlated with suicide have been considered at four different levels: individual, geographic, societal, and historical influences. The first, the individual, focuses on the influence of specific events in someone’s life and their affiliation with and participation in social groups. An approach at this level assumes that critical life events or circumstances are responsible for suicides. For example, individuals who face divorce, economic strain, or political repression are often characterized as suicide risks. Here, empirical research often relies on the case-control method, comparing at-risk individuals to others, often matched by age and gender. When considering the second level, the focus is on the geographic distributions of suicide, often within countries, and socio-cultural profiles are assessed to see if they contribute to the suicide rate. These studies rely on suicide rates and characteristics of geographical areas. For example, individuals living in areas of low social integration (e.g., high divorce or unemployment rates) have higher risk of suicide. Third, research at the societal level has examined differences in suicide rates cross-nationally. Different countries, having different institutional arrangements, differ significantly with respect to suicide. For example, Northern European societies, especially Finland and Austria, have especially high rates, as do many Eastern European post-Soviet countries (e.g., Hungary and Russia; see Chapter 2, Table 2-1), whose suicide rates reflect a general worsening of health conditions in a time of societal turmoil and crisis with vast economic, political, and social changes. Further, Confucian societies, Japan and China in particular, have comparatively higher suicide rates than other Asian societies. Moreover, the discrepancy between male and female rate of suicide is much smaller for Asian, especially East Asian, societies. At the historical level of analysis, suicide rates are compared over time periods, to examine either short period effects or longer-term trends. Trends can be examined and correlated with changes over time in social and cultural indictors for various societies. Although these studies use very different approaches and consequently are difficult to compare and analyze (see van Egmond and Diekstra, 1990), they do reflect the importance of understanding context and historical period. The following sections will explore many of the social and cultural factors that influence suicide and will draw upon data from these multiple levels.

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Reducing Suicide: A National Imperative Family and Other Social Support Across societies, family attachments influence suicide probability. Some researchers maintain that the family unit is the single most important factor in understanding suicide (e.g., in India, see Gehlot and Nathawat, 1983). However, others demonstrate that economic circumstance of life must also be considered (e.g., Leenaars and Lester, 1995, see also discussion of the interplay of these variables under occupation and suicide). Whatever the societal context, living alone increases the risk of suicide (Allebeck et al., 1987; Drake et al., 1986; Heikkinen et al., 1995). Family and other social support are protective factors, as will be discussed. My mother also was wonderful. She cooked meal after meal for me during my long bouts of depression, helped me with my laundry, and helped pay my medical bills. She endured my irritability and boringly bleak moods, drove me to the doctor, took me to pharmacies, and took me shopping. Like a gentle mother cat who picks up a straying kitten by the nape of its neck, she kept her marvelously maternal eyes wide-open, and, if I floundered too far away, she brought me back into a geographic and emotional range of security, food, and protection. Her formidable strength slowly eked its way into my depleted marrowbone. It, coupled with medicine for my brain and superb psychotherapy for my mind, pulled me through day after impossibly hard day (Jamison, An Unquiet Mind: A Memoir of Moods and Madness, 1995:118–119). Marital Status Marital status provides an opportunity to see the convergence of sociodemographic effects on suicide; its influence on suicide rates varies by gender, culture and across the life course. In general, however, across many cultures, marriage is associated with lower overall suicide rates, while divorce and marital separation are associated with increased suicide risk (Allebeck et al., 1987; Charlton, 1995; Heikkinen et al., 1995; Leenaars and Lester, 1999; Lester and Moksony, 1989; Motohashi, 1991; Petronis et al., 1990; Zacharakis et al., 1998). Widowed persons are also more likely to complete suicide (e.g., Heikkinen et al., 1995; Kaprio et al., 1987; Li, 1995; Ross et al., 1990; Zacharakis et al., 1998; Zonda, 1999). Other studies suggest that being single also influences the likelihood of committing suicide (e.g., Charlton, 1995; Heikkinen et al., 1995; Li, 1995; Qin et al.,

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Reducing Suicide: A National Imperative 2000). Results for suicide attempts and marital status are slightly different. As seen with completions, divorced and single individuals were over-represented among suicide attempters (Schmidtke et al., 1996). However, a study in the Netherlands found the lowest overall rates of attempts were among the widowed (Arensman et al., 1995), perhaps reflecting the lethality of attempts among this cohort (see Chapter 2). Cultural context provides insight into the role of marital status in suicide. In the United States, Stack (1996) found that among African-Americans, divorce or death of a spouse significantly raised the risk of suicide, but being single did not. The strength of the association between marital status and suicide was less than the effect for whites, which the author suggests is due to stronger family ties. The impact of marital status also differs for men and women, and varies across the life course. Models that account for gender often have found that divorce increases suicide risk in men only; in women divorce does not seem to exert a strong influence on suicide (e.g., Kposowa, 2000; Pescosolido and Wright, 1990). In Israel, increased divorce rates between 1960 and 1989 were associated with higher suicide rates for men and lower suicide rates for women (Lester, 1997). In contemporary Pakistan, suicides were more prevalent in married than unmarried women (Khan and Reza, 2000). One controlled study (Heikkinen et al., 1995) found that suicides were especially common among never-married men ages 30-39 compared to the general population. Theoretical interpretations of this data frequently echo the suppositions of Durkheim, who proposed that marriage is protective when it is not over- or under-regulating, and provides social integration and support through a strong family network (Durkheim, 1897/1951). For example, reflecting Durkheim’s notion that very early marriage for men is “over-regulating,” high proportions of never-married populations are related to lower suicide rates among young men (Pescosolido and Wright, 1990). Although the research in this area is incomplete, these results caution against generalizing on the basis of any single sociodemographic factor. Heikkinen and colleagues (1995) suggest that some of the age-related variations in social factors for suicide may be better explained by mental illness and alcohol abuse. An analysis by Qin and colleagues (2000) supported this theory. Controlling for psychiatric hospitalization, they found that marital status was no longer an independent significant suicide risk factor for women. Other research suggests that the quality of the marital bond may be most important; domestic violence seems to increase risk for suicide ideation and attempts across the world (McCauley et al., 1995; Muelleman et al., 1998; Roberts et al., 1997; WHO, 2001). It has also been suggested that when marital ties represent the only or primary source of

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Reducing Suicide: A National Imperative social integration and support, the dissolution of the marriage will have an especially strong effect on increasing suicide risk (Pescosolido and Wright, 1990). Integration of individual-level variables is necessary to understand the confluence of these factors. Parenthood Being a parent, particularly for mothers, appears to decrease the risk of suicide. In a prospective study of over 900,000 women followed for 15 years, Hoyer and Lund (1993) noted that both having children and the number of children decreased the risk of suicide. Across countries, having a young child appears to be a significant protective factor for women (de Castro and Martins, 1987; Qin et al., 2000). Pregnant women have a lower risk of suicide than women of childbearing age who are not pregnant (Marzuk et al., 1997). Family Discord and Connectedness Discord within the family also has an impact on suicide. Increases in the suicide rates in Ireland between 1970 and 1985 were correlated with a general decline in social cohesion as marked by a fall in the marriage rate and rise in the number of separated couples (Kelleher and Daly, 1990). A study in Scotland (Cavanagh et al., 1999) demonstrated that among patients with mental disorders, family conflict increased the risk of suicide by about a factor of 9. The effect of domestic discord also can influence the suicide rate for children and adolescents. Adolescents who had lived in single parent families or who were exposed to parent–child discord were more likely than matched controls to complete suicide (Brent et al., 1994; see also the case of young Canadians, Trovato, 1992). Furthermore, Tedeschi (1999) found that exposure to trauma, such as violence, predicts poor outcomes in children, especially if parental responses are inadequate (Bat-Aion and Levy-Shiff, 1993; Garbarino and Kostelny, 1993) (see also Chapter 5). But if parental physical and mental health are sound, children can do surprisingly well even in the face of terrorism (Freud and Burlingham, 1943; Miller, 1996). On the other hand, some researchers (Borowsky et al., 2001; Resnick et al., 1997) have noted that perceived parental and family connectedness significantly protected against suicidality for youth. Other studies also demonstrated a protective effect of family connectedness and cohesion on suicidal behavior among American Indian and Alaska Native youth (Borowsky et al., 1999), Mexican American teenagers (Guiao and Esparza, 1995), and a largely white sample of adolescents (Rubenstein et al., 1989).

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Reducing Suicide: A National Imperative Social Support Those who enjoy close relationships with others cope better with various stresses, including bereavement, rape, job loss, and physical illness (Abbey and Andrews, 1985; Perlman and Rook, 1987), and enjoy better psychological and physical health (IOM, 2001; Sarason et al., 1990). Studies have documented that social support can attentuate severity of depression and can speed remission of depression in at-risk groups such as immigrants and the physically ill (Barefoot et al., 2000; Brummett et al., 1998; Shen and Takeuchi, 2001). Studies of youth at risk for adverse outcomes, including suicide, have demonstrated that social support potently buffers the effects of negative life events (Carbonell et al., 1998; O’Grady and Metz, 1987; Vance et al., 1998). As mentioned above, completed suicide occurs more often in those who are socially isolated and lack supportive family and friendships (e.g., Allebeck et al., 1988; Appleby et al., 1999; Drake et al., 1986). Studies from across sundry countries and ethnic groups show that suicide attempts and ideation among youths and adults correlate with low social support (De Wilde et al., 1994; Eskin, 1995; Hovey, 1999; Hovey, 2000a; Hovey, 2000b; Ponizovsky and Ritsner, 1999), with one study suggesting that perceived social support may account for about half the variance in suicide potential for youth (D’Attilio et al., 1992). Research has demonstrated that social support moderates suicidal ideation and risk of suicide attempts among various racial/ethnic groups, abused youths and adults, those with psychiatric diagnoses, and those facing acculturation stress (Borowsky et al., 1999; Hovey, 1999; Kaslow et al., 1998; Kotler et al., 2001; Nisbet, 1996; Rubenstein et al., 1989; Thompson et al., 2000; Yang and Clum, 1994). Evidence suggests different mechanisms of support’s influence. Social support sometimes represents part of a protective process that increases self-efficacy and thereby reduces suicidal behavior (Thompson et al., 2000). At other times social support more directly reduces suicidality via reducing psychic distress (Schutt et al., 1994). Furthermore, family and friendship support appear to play somewhat different roles in protecting against suicidality (Rubenstein et al., 1989; Veiel et al., 1988); men and woment may differ in use and types of social support (Heikkinen et al., 1994; Mazza and Reynolds, 1998). Effective treatment for suicidality, whether medical or psychosocial, involves human contact and support (see Chapter 7). Recent suicide prevention programming to increase social support and other positive variables (e.g., Thompson et al., 2000) builds on emerging evidence suggesting a greater ameliorative effect of increasing protective factors than reducing risk (Borowsky et al., 1999; Vance et al., 1998).

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Reducing Suicide: A National Imperative Religion and Religiosity In general, participation in religious activities is a protective factor for suicide. In the United States, areas with higher percentages of individuals without religious affiliation report correspondingly higher suicide rates (Pescosolido and Georgianna, 1989). Annual variation in the suicide rate tends to correlate with annual variation in church attendance (Martin, 1984). Furthermore, older adults (50 or more years of age) who are involved with organized religion are less likely to complete suicide (Nisbet et al., 2000). Similarly, areas in the former Soviet Union with a strong tradition of religion had lower suicide rates from 1965 to 1984 (e.g., the Caucasus and Central Asia; Varnik and Wasserman, 1992). The protection afforded by religion may have several components. Involvement with religion may provide a social support system through active social networks (see Stack, 1992; Stack and Wasserman, 1992). Suicide may be reduced with religious affiliation because of the proscription against the act (e.g., Ellis and Smith, 1991). Belief structures and spiritualism may also be protective at an individual level as a coping resource (e.g., Conway, 1985-1986; Koenig et al., 1992) and via creating a sense of purpose and hope (see Chapter 3 on these protective factors) (e.g., Herth, 1989; Werner, 1992; 1996). Religious Affiliation Historically, studies of Western Europe indicated that those countries or regions within countries that were Catholic as opposed to those that were Protestant had lower suicide rates; this has been proposed to be related to increased social contact and affiliation in practiced Catholicism (Durkheim, 1897/1951; Masaryk, 1970). In the United States, this classic hypothesis also has received empirical support (Breault, 1986; Lester, 2000b). However, unlike much of Europe, the United States has experienced intensive and widespread denominationalism among Protestant groups. While religion continues to be correlated differentially with suicide, it appears that areas with both a greater presence of Catholics and evangelical or conservative types of Protestantism (e.g., Southern Baptist) report lower suicide rates compared to those with higher representation of mainline or institutional Protestantism (e.g., Episcopalian, Unitarian). The presence of Jewish adherents results in a small but inconsistent effect on reducing suicide rates (Pescosolido and Georgianna, 1989). However, the proportion of Islamic adherents does not appear to be related to suicide rates (Lester, 2000a). This research points to the social ties formed (by volition and obligation) across these different religious groups rather than differences in

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Reducing Suicide: A National Imperative dogma. This conclusion is further supported by evidence that indicates that in the “historical hubs” of religions (e.g., Lutherans in the Midwest, Jews in the Northeast), the protective effects of religious affiliation are stronger. Conversely, where religious adherents are located outside of these places, the effect of affiliation on suicide (e.g., Jews and Catholics in the South) may produce more suicides. It has been suggested that it is precisely in those places where religions have constructed institutions of assistance and informal communities of support that religion’s protective effects are strongest (Pescosolido, 1990). Studies at the individual level of assessment further explicate the role of religion in reducing risk of suicide. Maris (1981) compared suicide rates among Catholics and Protestants in Chicago between 1966 and 1968. He found that for all age groups and across both sexes, the suicide rate for Protestants was greater than the suicide rate for Catholics. Immigrants to the United States who identified as Catholic report significantly lower lifetime rates of suicide ideation (3.7% vs. 11.8%) and suicide attempts (1.6% vs. 2.6%) than non-Catholic immigrants. Scores on church attendance, perception of religiosity, and influence of religion were negatively associated with suicidal ideation. When sex, marital status, and socioeconomic status were factored in, the perceived influence of the religion item was the strongest significant independent predictor of suicidal ideation. Those individuals who perceived religion to be influential in their lives reported less suicidal ideation, and those individuals who attended church more often reported less suicidal ideation. These findings yielded no support for the notion that affiliation with Catholicsm shows less suicide risk than with other religions, as church attendance rather than religious affiliation accounted for most of the variation in suicide attitudes. These findings do, however, lend support to the notion that religiosity plays a protective role against suicide. Although most studies of religion and suicide have focused on adult samples, some have found that church attendance among youths of various ethnic/racial backgrounds reduces suicide risk, including suicide attempts (Conrad, 1991; Kirmayer et al., 1998; 1996). A large meta-analysis of U.S. adolescent data that controlled for sociodemographic variables indicates that religiousness decreases risk of suicide ideation and attempts in youths (Donahue, 1995). Religious Beliefs Actively religious North Americans are much less likely than nonreligious people to abuse drugs and alcohol (associated with suicide), to divorce (associated with suicide), and to complete suicide (Batson et al., 1993; Colasanto and Shriver, 1989). Stack and Lester (1991) found that those individuals who attended church more often reported less approval

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Reducing Suicide: A National Imperative of suicide as a solution to life’s problems. In a study involving 100 college students, Ellis and Smith (1991), using the Reasons for Living Inventory (Linehan et al., 1983) and the Spiritual Well-Being Scale (Paloutzian and Ellison, 1982), found results that strongly indicate a high positive relationship between an individual’s religious well-being (faith in God) and that person’s moral objections to suicide; existential well-being correlated with adaptive survival and coping beliefs (see Chapter 3). Decades-long study of at-risk individuals has also suggested that religious involvement and beliefs can influence positive outcomes by providing persons with a sense of meaning and purpose (Werner, 1992; 1996). Several epidemiologic studies have reported lower rates of depression among religious persons, whether healthy or medically ill (Kendler et al., 1997; Kennedy et al., 1996; Koenig et al., 1992; Koenig et al., 1997; Pressman et al., 1990). Koenig et al. (1998) also found that intrinsic religiousness (i.e., religious beliefs representing a person’s primary, unifying life motive) significantly increased the speed of remission from depression by 70 percent for every 10-point increase on the Hoge Intrinsic Religiousness scale. These changes were independent of other factors predicted to speed remission, including changing physical health status, religious activity, and social support. Religious activity has also been found to be protective against suicide risk factors such as alcohol abuse, drug abuse, and anxiety disorder (Braam et al., 1997a; Braam et al., 1997b; Gorsuch, 1995; Koenig et al., 1992; Koenig et al., 1993; Koenig et al., 1994; Pressman et al., 1990). Further, a number of studies provide some evidence that spiritual protective factors (e.g., religious beliefs) may inoculate individuals against stressful life experiences (Conway, 1985-1986; Koenig et al., 1999; McRae, 1984; Pargament, 1990; Pargament et al., 1998; Park and Cohen, 1993; Park et al., 1990). At least one study has found attenuation of immune-inflammatory responses in those who regularly attend religious activities that could not be explained by differences in depression, negative life events, or other covariates (Koenig et al., 1997). Koenig et al. (1998) noted that using spiritual/religious practices to treat depression and anxiety has been found effective. Propst et al. (1992) found religious therapy resulted in significantly faster recovery from depression when compared with standard secular cognitive-behavioral therapy. Similarly, Azhar et al. (1994) randomized 62 Muslim patients with generalized anxiety disorder to either traditional treatment (supportive therapy and anxiolytic drugs) or traditional treatment plus religious psychotherapy. Religious psychotherapy involved the use of prayer and reading verses of the Holy Koran specific to the person’s situation. Patients receiving religious psychotherapy showed significantly more rapid improvement in anxiety symptoms than those receiving traditional

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Reducing Suicide: A National Imperative I like living. I have sometimes been wildly, despairingly, acutely miserable, racked with sorrow, but through it all I still know quite certainly that just to be alive is a grand thing. —AGATHA CHRISTIE