Factors that contributed to "undetermined" attitudes included male gender, younger age, lower education level, greater severity of depression, and lack of personal experience of an acquaintance's suicide. Passive thoughts regarding suicide prevention and the promotion of mental health in the community were significantly associated with male gender, younger age, lower education level and greater severity of depression.
Many of the studies have reported that female gender is associated with a higher prevalence of poor mental health status than male [16–24]. Vahtera et al. [20] suggested that women are more affected by the aftermath of death or illness in their extended family than are men. Two studies have found that women tend to complain about stressful interpersonal events, whereas men tend to complain about stressful legal and work-related events [21, 22]. Another review, however, suggested that men were more vulnerable to stressful events such as the loss of their partner [25]. Gender differences in the vulnerability to stressful life events were uncertain. Our results indicated that women would feel deeper sympathy than men for those mourning a death by suicide and might be more sensitive to bereaved individuals. Determining effective social support from within the community for individuals grieving the suicide of a friend or family member will require a consideration of gender differences.
Younger people tended to show "undetermined" attitudes towards those bereaved by suicide more than older people did. We considered the possibility that this association may be due to the relative inexperience of young people with bereavement. Although there are no data on the relationship between age and attitudes towards those bereaved by a suicide, studies of the relationship between age and worry (i.e., as assessed by Worry Scale or the Penn State Worry Questionnaire) show that older adults have reported low levels of worrying [26, 27]. Powers et al. reported that the elderly worry significantly less than those who are relatively young [28]. These authors interpreted these results in terms of lifecycle span and experience. Our results support their findings.
The correlation between passive thoughts regarding suicide prevention and the promotion of mental health in the community and younger age may be understood as a result of disinterest owing to a relative lack of experience of young people with death from any cause.
Many studies have reported significant correlations between level of education and mental health status [23, 24, 29–31]. Wolff et al. [32] reported that attitudes of goodwill towards people suffering from mental illness were significantly associated with higher levels of education. It is possible that people with lower levels of education express unhelpful attitudes towards those grieving the suicide of a loved one because of a general ignorance about mental health issues. For example, Kaneko et al. [33] reported that low mental health literacy was strongly associated with low levels of education. People with low levels of education may display the undetermined or inappropriate attitudes reported here because they know less about suicide and mental illness.
Beck et al. [34] proposed that depression emerges from dysfunctional cognitions that initiate and maintain the emotional, motivational, and behavioural symptoms that define this condition (e.g., dysphoric mood, lack of motivation, and low energy level). Additionally, the features of depression include reduced energy and diminished activity [35]. These symptoms of depression are consistent with our finding of an association between inappropriate or undetermined attitudes, and greater severity of depression.
Personal experience, or the lack thereof, of involvement with individuals who commit suicide appears to affect attitudes towards those grieving a death by suicide. Addison et al. [36] reported that people who had personal experience of people suffering from mental illness were generally more positive in their attitudes towards people with mental illness compared to those who had no such experience. Our results support the notion that personal experience affects attitudes towards others who are similarly situated. Harwood et al. [37] reported that relatives and friends grieving a death by suicide scored higher than those grieving deaths by other causes in measurements of stigma, shame, sense of rejection, and unique reactions. They found that bereavement following suicide affects not only family but also friends and neighbours. This may explain our finding that appropriate attitudes in the form of expressions of feelings for those mourning a death by suicide is related to a history of personal contact with someone who commits suicide as compared with undetermined attitudes.
Those who displayed undetermined and inappropriate attitudes towards those bereaved by a suicide tended to focus less on the bereaved persons than did those who displayed appropriate attitudes. We categorised "offering to talk" as an appropriate attitude. However, those who indicted they would offer to talk also require education about appropriate ways of talking, language use and grief procedures. Further studies will be needed to improve the social support for those bereaved by suicide and to reduce their psychological burden.
Several limitations pertaining to our study should be noted. Because we used a cross-sectional design, we could not determine causal relationships. Second, the use of a self-administered questionnaire may have led to reporting bias, perhaps especially in relation to items about personal experience of an acquaintance's suicide. Although this may have had a role in the responses proffered by older subjects, similar results were obtained when the sample was stratified by age. Third, our study did not include other causes of death such as natural or accidental death. However, some studies have indicated that the social response to death by suicide differs from responses to other causes of death including natural death [12, 13]. Therefore, we consider that our results sufficiently should reflect attitudes toward those bereaved by a suicide. Strategies for improving attitudes and perceptions within the social network of an individual who is bereaved by a suicide should be helpful for the individual afflicted by grief.
Of the 6383 respondents, 5154 answered all of the items used in the logistic regression analyses. The analyses included 68.5% of residents in the survey area aged 30–69 years. The percentage of unanswered questions were respectively as follows: gender, 2.0%; age, 2.6%; level of education, 1.7%; level of depression, 13.1%; and personal experience of an acquaintance's suicide, 3.4%. Of the 1229 respondents who did not complete the questionnaire, 41.6% were male, 10.6% were aged in their 30s, 12.8% had an educational background of 13 or more years, 30.3% had no depressive symptoms (normal) based on a self-rated depression scale, and 41.9% had an acquaintance who had committed suicide. Males, younger people, those with higher levels of education, those with no depressive symptoms, and those who had personal experience of an acquaintance's suicide returned questionnaires with significantly more complete answers than did others. No statistically significant differences with respect to attitudes towards those bereaved by suicide appeared between complete responders and incomplete responders. However, a statistically significant difference appeared between complete and incomplete responders with regard to perceptions regarding suicide prevention and mental health promotion the community. Levels of concern about suicide among the residents questioned may have influenced these differences.
The community of the area that we studied experiences many deaths by suicide. Prevention of suicides is needed. In developing effective community suicide prevention programs, our results should be taken into account and utilised to educate the community regarding appropriate attitudes and actions.
