High rates of childhood abuse, depression in Inuit suicides
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* Laura Eggertson

The first psychological-autopsy study in the world to focus on the causes of the elevated rates of suicide among Inuit in Nunavut has found high rates of childhood sexual and physical abuse, depression, and alcohol and marijuana abuse in the histories of 120 people who took their own lives between 2003 and 2006.

Researchers at the McGill Group for Suicide Studies and McGill’s Douglas Mental Health University Institute in Montréal, Quebec released *Qaujivallianiq Inuusirijauvalauqtunik, Learning from Lives that Have Been Lived*, at a news conference June 5 in Iqaluit.

“Suicide is an issue that affects us all,” Cathy Towtongie, president of Nunavut Tunngavik Inc., told the news conference. “This study provides us with a clearer understanding of the reasoning behind suicide. It’s my hope that it will lead to a better understanding of suicide and allow for a better prevention of suicide in the future.”

In conducting the Nunavut suicide follow-back study, the researchers reviewed medical and RCMP records, and interviewed family and friends of 120 Inuit, aged 13 to 62, who completed suicide in the territory in that period. They compared this group to 120 people in Nunavut who had similar dates of birth, came from the same community of origin and were the same sex as those in the suicide group. The researchers interviewed 498 people in total to identify the reasons behind each death and to better understand and prevent suicide.

Jack Hicks, one of the researchers who conducted the interviews for the study, reports that suicide among Inuit in Nunavut occurs at a rate of about 110 deaths per 100 000 people, which is about 10 times the rate in the rest of Canada (11 per 100 000). Among young men aged 15 to 24 in Nunavut, the suicide rate is more than 500 per 100 000 — close to 50 times the national rate for this group.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/185/10/E433/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/185/10/E433/F1)

Inuit youth working with the Embrace Life Council in Iqaluit created this mural to promote suicide prevention efforts.

Image courtesy of Laura Eggertson

In 2012, there were 27 completed suicides by Inuit in Nunavut, which has a population of about 34 000. This year, there have been 21 suicides so far. Those deaths included a 13-year-old girl who hung herself, followed by her grandmother, who also hung herself in Pangnirtung, a day after her granddaughter’s funeral.

The two most important findings of the new study are that mental illness is a substantial risk factor for suicide among the Inuit and that sexual and physical abuse have a serious impact, says Dr. Eduardo Chachamovich, a psychiatrist and assistant professor at McGill University. Chachamovich coauthored the report on the study, which was funded by the Canadian Institutes of Health Research and the Government of Nunavut.

Among the suicide group, 54% suffered major depressive disorder in the last six months of their lives, compared with 8.3% of the comparison group. In addition, 61% of the suicide group and 24% of the comparison group had experienced major depressive disorder at some point before their final six months of life — much higher than the national average. In the general Canadian population, 8% of people will experience major depression at some time in their lives.

As well, 89% of the suicide group were diagnosed with more than one mental health disorder, compared to 29% of the comparison group. The researchers diagnosed psychiatric disorders after the fact, using specific medical criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

In the suicide group, only 12.5% had taken psychiatric medication in the past. Most — 89% — had never taken medication for a mental illness and only 17% had ever been hospitalized for mental health problems.

The study also makes a strong association between suicide and childhood physical, sexual and emotional abuse. Almost half (47.5%) of the suicide group were abused in childhood, compared to almost a third (27.5%) of the comparison group. When separated out, 15.8 % of the suicide group experienced sexual abuse in childhood, compared to 6.7% of the comparison group. In addition, 21% of the suicide group experienced physical abuse in childhood, compared to 13.3% of the comparison group.

“The link between childhood sexual and physical abuse and over-arching risk for suicide is something that is very pronounced in the study and it reinforces our concern about these topics,” Natan Obed, director of Nunavut Tunngavik Inc.’s Department of Social and Cultural Development, told *CMAJ* in an interview. Nunavut Tunngavik is the organization administering Inuit responsibilities under the Nunavut Land Claims Agreement.

“We don’t feel we can make huge strides on suicide prevention or a host of other mental health conditions unless we do more to ensure that children are growing up in safe and healthy environments,” Obed says.

Nunavut needs an infusion of short-term resources from the federal government to help deal with suicide prevention, including measures such as targeting child sexual and physical abuse, and providing a continuum of culturally appropriate mental health services, Obed says. Territorial leaders also need to stand up and speak out about the unacceptable levels of child abuse, he says.

This study follows the Auditor General of Canada’s 2011 report documenting the incidence rate of sexual violations against children in Nunavut — 44.3 incidents per 100 000, compared to the national rate of 4.3 incidents per 100 000.

“If we had those figures anywhere in the south, it would be a major crisis,” Chachamovich said in an interview with *CMAJ* from Montréal, Quebec. “People would be talking about it every day in the papers, on the streets. There would be a big outcry for more resources and more help.”

The number of people who experienced sexual abuse is in fact likely under-reported, adds Chachamovich. This is suggested by figures gathered during the *Qanuippitali Inuit Health Survey* from 2007–2008. That report, released in September 2012, indicates a staggering 41% of Inuit in Nunavut suffered severe sexual abuse as children. The survey of 1710 Inuit was conducted as part of a community and personal wellness questionnaire. In the survey, 31% of respondents also reported severe physical abuse during childhood.

The new study’s results are consistent with the medical literature about the causes of suicide generally, Chachamovich adds. “But this is the first study where those risks are documented in Inuit and documented in a way that is hard to ignore. It’s not that we are finding things that are surprising or unique — but we are finding things that need to be addressed.”

Given the high need for mental health treatment and intervention to stop child abuse, it is particularly poignant that so few people were prescribed treatment, says Chachamovich. Since suicide is the outcome of a process that starts early in people’s lives, identifying the risks and intervening makes it possible to reduce completions. Unfortunately, the unmet needs in Nunavut are high, he says.

“The resources are very limited and they don’t respond to the need.”

Often, experts debate whether mental health problems are a risk factor for Inuit at the same rate as for southern populations, says Chachamovich.

“Some people will say mental health is not a factor — that [risk] has only to do with trauma and cultural changes and [historical] relocation. Our findings show that … mental health problems are even greater in Nunavut than they are here, which also means of course that delivering mental health care services is also very important and should have an impact on reducing the rates of suicide, the same way it does here.”

The study also found higher rates of impulsivity and aggressiveness associated with those who completed suicide.

The study’s authors hope the Government of Nunavut, the communities in the territory and the federal government will begin to address the risk factors the researchers identified “more systematically and consistently,” says Chachamovich.

There are no psychiatrists in Nunavut, no permanent family doctors in many communities, and even visiting psychiatrists and family doctors may not reach some of the territory’s more isolated communities for months at a time. That’s not good enough, given the rates of mental illness, substance abuse and family violence, Chachamovich says. Consistent, aggressive delivery of programs such as ASIST — Applied Suicide Intervention Skills Training — is required.

“We are not doing that currently — that’s clear — and the numbers show us,” says Chachamovich. “The suicide rate is not going down.”

“The model of health professionals waiting for people to come and talk to them about whatever is happening — a passive model — it doesn’t work up there,” says Chachamovich. “You have to have an active model where you go and reach people.”

**Editor’s note:** This is the first of a four-part series at cmaj.ca on suicide in Nunavut, Canada.