Needs Assessment: Although suicide in Micronesia is unique in cross-cultural comparison, relatively little research has systematically investigated suicidal behavior in this area. Limited knowledge of suicidal behavior prohibits the development of suicide prevention. Researchers and clinicians should have the knowledge for development of more culturally responsive suicide prevention and intervention strategies.
• Recognize the characteristics of suicide in the Micronesia area.
• Understand the relationship between mental disorders and suicide.
• Understand the importance of cultural factors on suicidal behavior.
Target Audience: Primary care physicians and psychiatrists.
CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.
This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: October 16, 2007.
Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.
To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by November 1, 2009 to be eligible for credit. Release date: November 1, 2007. Termination date: November 30, 2009. The estimated time to complete all three articles and the posttest is 3 hours.
Dr. Ran is associate professor at the School of Nursing and Health Sciences at the University of Guam in Mangilao, Guam.
Acknowledgments: The author thanks Professor Yeates Conwell, MD, of Department of Psychiatry at the University of Rochester for his advisory and editorial support, and Professor Donald H. Rubinstein, PhD, of the University of Guam for his support.
Disclosures: Dr. Ran is a lead consultant for the Suicide Research and Prevention Project at the Department of Mental Health and Substance Abuse in Guam.
Please direct all correspondence to: Mao-Sheng Ran, MD, PhD, School of Nursing and Health Sciences, University of Guam, Mangilao, Guam 96923; Tel: 671-735-2655; Fax: 671-734-1203; E-mail: email@example.com.
Introduction: What are the characteristics of suicide in Micronesia? Limited knowledge of suicidal behavior prohibits the development of culturally responsive suicide prevention in Micronesia. This study explores the status of suicide and provides recommendations for further research and prevention programs.
Methods: All the available studies on suicidal behavior in Micronesia were reviewed.
Results: Since the late 1960s, the number of suicides through Micronesia has risen sharply. There is a strong preponderance of male over female suicides (male versus female=10–16:1). The victims are generally young males between 15 and 24 years of age. The suicide rates, especially among youths, are amongst the highest in the world. The most common scenario leading to suicide is an incident of intergenerational conflict. Less than 40% of suicides occur in people with mental disorder.
Discussion: Suicide in Micronesia is unique in cross-cultural comparison. However, relatively little research has systematically investigated suicidal behavior in this area.
Conclusion: Further studies should focus on the risk and protective factors—especially sociocultural factors—of suicidal behavior using standardized instruments and diagnostic criteria. Suicide prevention might focus on improving public education, mental health services, and crisis intervention.
Suicide is a significant public health issue and a leading cause of death in the world, claiming approximately 1 million people annually worldwide.1 In 2004, the suicide rate in the United States was 11.05 per 100,000, equaling 32,439 people.2 Although many studies on suicide have been conducted in the US, many previous studies of suicide incorporated Micronesian populations into the broad category of Asian Americans and Pacific Islanders. Consequently, the ability to make important distinctions between Micronesians and others and among subgroups in the Micronesian population were lost.3-5 The categorization of Pacific Islanders ignores that this group may actually reflect many diverse ethnic groups (eg, Hawaiians, Samoans, Micronesian). Existing evidence indicates that Asian groups have been found to have substantially lower rates of completed suicide than those of white people, whereas rates of completed suicide among Pacific Islanders including Micronesian populations are some of the highest in the world.6,7 Disaggregated suicide data on US Pacific Islander populations, especially Micronesian populations, are limited.5
Suicide is a significant public health issue and has long been a feature of Micronesian cultures.8 Micronesian adolescent suicide in particular has received notice since 1976.9 Currently, within some island nations of the Pacific region, suicide is the leading cause of death for young adults, and youth rates are among the highest in the world.7 Although culture may play a role in suicidal behaviors, cross-cultural research is lacking in suicidology.10,11 As limited research on suicidal behavior, especially among different islanders, has been conducted in Micronesia, the characteristics of suicide among Micronesian people are still unclear, preventing the development of evidence-based approaches to suicide prevention.
The aim of this article is to explore the characteristics of suicidal behavior in this specific area and to make recommendations for further research and prevention among Micronesian populations. This will provide researchers and clinicians with knowledge necessary for development of more culturally responsive prevention and intervention strategies.
There is considerable linguistic and cultural diversity throughout Micronesia.12 Significant cultural differences exist from one main island group to another. Politically, the region is also very diverse, resulting from the successive eras of foreign colonial activity in the Western Pacific.13 The Micronesian region of Western Pacific generally includes one unincorporated American territory (Guam); one US Commonwealth of Northern Mariana Islands (CNMI); and the Pacific Island Nations of Micronesia, which include the Federated States of Micronesia (FSM), the Republic of Belau (Palau), and the Republic of the Marshall Islands that have signed unique contracts of “free association” with the US.
During the past 55 years Micronesian communities have experienced rapid sociocultural transformation toward increasing reliance upon cash economy and government employment; American-style schools and health services; and modern forms of technology, consumer goods, transportation and communication. Today, Micronesians live in two worlds, including the still-intact communities of the rural and outer islands, and the increasingly Americanized urban centers.12 Within the Micronesia area, there are approximately 15 different languages spoken. English is an official language of these Pacific Islands, but proficiency levels vary immensely. Religious practices include Catholic, Protestant, and others.13
The total estimated population of the area including indigenous Micronesians and immigrants is approximately 352,472, of which almost half is located on the island of Guam (171,019 in 2006).14 Based on the 2000 US Census,15 there are 874,414 Pacific Islanders, 0.3% of the total US population (Micronesians: 13.2% of Pacific Islanders: 80.1% Chamorro; 0.5% CNMI, 1.8% FSM, 5.8% Marshallese; 3% Belauan; 8.6% non-specified Micronesian).
An electronic literature search of all articles published from 1966 to the latest publication available (2007) was conducted via MEDLINE, PsychINFO, and ScienceDirect to identify reports about suicidal behavior and suicide prevention in Micronesia. The search used the identifier “suicide” (including the subheading “suicide, attempted, ideation, prevention”) and the subheading “Micronesia and Guam.” Moreover, all other available studies reported about suicidal behavior in Micronesia were also collected, through key references from the literature already accumulated and suggestions from experts in these fields. Abstracts and full-text articles were retrieved and reviewed.
Trend of Suicide
The suicide rates in Micronesia have risen in epidemic fashion since the late 1960s. More than 500 suicides have been recorded for the US Trust Territory (exclusive of the Northern Marianas) from the early 1960s to the early 1980s.16-18 From the early 1960s to the early 1980s, suicide rates overall in Micronesia more than doubled every decade (Figure 1).9,13,16,18-21 From 1960–1967 the suicide rate for the Micronesian population overall was fairly low (4–5 per 100,000 population); the rate doubled during 1968–1975, reaching 22 per 100,000 people in 1972–1975. The most rapid increase had occurred during the 1970s. The rate continued to climb, although less rapidly, until 1980–1983, when it reached 30 per 100,000 people. During 1984–1987, the suicide rate leveled and declined significantly to 26 per 100,000 people.13 The suicide rate in Micronesia is one of the highest rates in the world.7,21 However, the trend in suicide rates from 1990s to the present in Micronesia is unclear due to the paucity of research data.
The rate of suicide on Guam increased sharply since the end of 1980s, peaking at 28.2 per 100,000 people in 1999 (Figure 1).22 However, there has been a sharp decline after 2000 on Guam.21 Rates have fallen back to 10.7 per 100,000 people in 2004.
The relative frequency of suicide on Guam differs by ethnic group.21 Indigenous Micronesians are considerably overrepresented among Guam suicide cases. They account for 27% of Guam suicides, although they constitute only 8% of Guam’s 2000 population. Filipinos have a relatively low suicide rate. Although the results indicate that ethnic differences appear striking, there are insufficient data on the ethnic subgroups to lend further insight into the issue.
There is a strong preponderance of male suicides over female suicides in Micronesia (Figure 1).7,13,20,23 The male-to-female suicide ratio was 3:1 during the years 1922–1939, 5.3:1 pre-1960, and 11.5:1 post 1960. The suicide rate of Micronesian males increased eight-fold during the 2 decades (1960–1979).16 In a study of 13 Pacific Island nations (excluding Hawaii), Booth7 reported that the differences in rates increased dramatically when youths (15–24 years of age) were disaggregated and examined by gender for Western Samoa (64 males, 70 females), Guam (49 males, 10 females), Chuuk State (182 males, 12 females), and Micronesia (91 males, 8 females). On Guam, male suicides outnumber female suicides by a factor of five (83.5 versus 16.5 percent) from 1998 to 2000.21
During the past four decades, suicide has become the primary cause of death for Micronesian youths.9,24 During the period from 1960–1987, 57% of suicides in Micronesia overall were in the 15–24 years of age group (Figure 2).13,20,22,25 Suicides in Micronesia display an essentially unique age distribution, peaking in the age bracket from 20–24 years for males (with a suicide rate of 110 per 100,000 people annually), and peaking in the age bracket from 15–19 for females (with a suicide rate slightly over 10 per 100,000 people annually).9,16 The median age of suicide is younger for females than for males.7 The suicide rates in youths in Micronesia, especially for men between 15 and 24 years of age, have achieved the tragic distinction of being among the highest in the world (Figure 3).7,9,13,22,25
Although Micronesian populations showed an age distribution where male suicides rose sharply from adolescence and peaked at ages 20–24, the age distributions after this peak differed for each subpopulation. Chuukese and Marshall Islanders had a dramatic decrease followed by a smaller peak at 60–65 years of age, while Belauan, Pohnpeans, and Yapese showed steady decreases after 39 years of age without a bimodal increase among elders.5 Similar to Hawaiians, indigenous Pacific Islanders from Micronesia and Guam have rates of completed suicide that increase sharply from adolescence to young adulthood, with rates dropping at 30 years of age and continuing to drop for middle-aged and elderly people.7,9
On Guam, suicide was the first leading cause of death for 20–34-years-old people, and the second leading cause of death for people 10–19 and 35–39 years of age (1993–2000; Figure 2). During 1998–2002, the age-specific suicide rates were 48.4 per 100,000 people for those 15–24 years of age, 26.3 for people 25–34 years of age, and 19.9 for people 35–44 years of age.22 All these rates were significantly higher than in the US mainland.25 Age-adjusted suicide rates in Guam were 67% higher than in the US mainland.22
Among the different Micronesian island groups, suicide rates varied from place to place, suggesting that cultural differences influence suicides.9 The peri-urban fringe areas have the highest rates of suicide.12,16,19,26 The most urbanized town areas have somewhat lower rates of suicide, while the most rural areas and outer-island communities have the lowest rates. The highest rates were found in Chuuk during the 10-year period in people 15–24 years of age, wherein 1 in 40 Chuukese boys commited suicide.
Methods of Suicide
The most common method of suicide in Micronesia among both men (86%) and women (69%) is by hanging.13,20 In Micronesia, hanging usually takes the form of leaning into a noose from a standing or sitting position. The primary method of suicide in Guam was by hanging as well, accounting for >50% of the cases during the 1980s and 1990s. On Guam, males usually employ more lethal methods than females.21 The strong preference in Micronesia for suicide by hanging may reflect the cultural patterning of the act which has not been influenced by foreign models.13
Mental illness did not appear to be an important factor in Micronesian suicides.13 Most of the victims have had no serious delinquency problems, psychological abnormality, or psychosis. Only a small percentage of suicide victims (Micronesia, 10%; Palau, 34% to 37%) showed any evidence of psychopathology.13,20,27 No obvious patterns of physical or psychological illness were found among the suicide victims.9 Among the victims with serious mental disorders, many of them were diagnosed with schizophrenia. Most of these victims have undergone treatment at some time in their lives for their mental illness.
However, repeated studies conducted worldwide over the past 3 decades indicate that >90% of suicide victims have a psychiatric disorder at the time of death.28-30 Although some studies did not show such a high percentage of psychiatric disorder, there were still 63% of suicide victims with a psychiatric disorder at the time of death in China31 and 62% with a documented history of mental illness in Hawaii (Figure 4).5
Alcohol and Substance Abuse
Alcohol is part of the suicide motivation or method.9 Evidence indicated that 41% to 68% of suicide victims were intoxicated or drinking at the time of suicide, and 34% of suicide victims (male 41%, female 7%) had a history of heavy drinking or drug abuse.12,13 This result is higher than the rate of alcohol use in Hawaii in which 31% of suicides tested positive at autopsy for alcohol use, with heavy alcohol use more common in youths.5 The reasons need to be explored further.
Precipitating Factors for Suicide
Intergenerational conflict is the most common scenario leading to suicide.20 Suicide is consistent with the Micronesian preferences for dealing with serious interpersonal domestic problems by withdrawal rather than confrontation. Most suicides were precipitated by a quarrel, argument, or misunderstanding between the young victim and someone very close to him or her, especially family members such as parents or another older relative.13,20,26 Older victims are often offended by their children or other younger people who are expected to serve as their care takers.20 Often, the preceding event seemed oddly trivial, and the response of suicide appeared completely out of proportion to the event.8,9,13 Many of these suicides appeared to be very impulsive acts rather than premeditated or planned actions.9
Hezel8 identified three major patterns of Micronesian suicides including anger suicides (50% to 85% cases), shame suicides (4% to 27% cases), and psychotic suicides (2% to 34% cases). The dominant emotion at play in suicide in Micronesia is anger.13,16,20 Anger toward a parent or other authority figure in the immediate family is often the cause for the suicide act.13 The definition of “anger” was similar to the way Americans describe depression.5
Suicide Attempts and Suicidal Ideation
Official data on suicide attempts in Micronesia are nearly nonexistent.13 Evidence indicates that only 20% to 25% of the suicide cases might reveal any prior intentions toward suicide by indirect statements or acts that could be interpreted as communication of suicidal ideation.13,16 The ratio of parasuicides to suicide is likely to be much higher (eg, 5 to 1 in Truk Lagoon).13 The sample of suicide attempts appears somewhat different (eg, age distribution, gender ratio, preferred method) from the completed suicide cases. Although males have higher rates of suicide, females have higher rates of suicidal ideation and attempts.21 Among the sample of suicide attempt cases, the preferred methods tend to be less lethal than among the completed suicide cases.13
Although suicidal ideation among adolescents appears widespread in certain Micronesian communities, there is no systematic survey to explore this issue. Only one study documents suicidal thoughts and attempts in Guam’s Asian/Pacific Islander adolescents with a probability sample.32 Results of one survey of high school students in Guam indicated that adolescents who reported suffering physical abuse in the context of a romantic relationship, engaging in binge drinking, and experiencing feelings of hopelessness were at greater risk for suicidal ideation and attempts.32 Girls were more likely than boys to indicate that they had attempted suicide during the past 12 months (28.2% versus 14.5%, respectively).
Race and ethnicity is related to suicide risk among adolescents.32 Among boys, risk for suicidal ideation is higher for Micronesians than for members of all other races and ethnicities. Compared with Micronesian girls, the risk of female suicidal ideation is reduced both for whites and for other races and ethnicities (ie, Hispanic, African American, other Pacific Islanders), whereas the risk of female suicide attempt is reduced only for other races and ethnicities. Given suicide attempts are more common among Micronesian boys,33 these results may actually understate the effect of Micronesian race or ethnicity for boys.
The rates of suicide in Pacific Islanders including Micronesian populations are among the highest in the world.7 The reasons for a high suicide rate observed in this area may include the following. First, the changes following World War II in family structure or parent-adolescent relations may be the underlying cause of the increase in adolescent suicide between the 1960s and 1980s.9,13,20 The expansion of a cash economy in Micronesia and the decreasing reliance on subsistence production in favor of store-bought produce has seriously eroded the importance of lineage and clan activities. This, in turn, has undermined the wider social supports for adolescents and brought about their unaccustomed dependency upon the nuclear family, resulting in a sharp increase in parent-adolescent conflict. Second, the acceptance of suicide is one of the reasons for a high suicide rate.20 The suicide act is seen as resolving characteristic social problems that individuals face in society.13 As suicide has gained familiarity among youths, the act itself has become more acceptable or even expected.9 Micronesian beliefs in spirit communication may also be an important factor for contagious influence from one suicide to another.13
Suicide rates and patterns between Micronesian populations with other indigenous populations in the US, Canada, and New Zealand are similar to some extent.5 For all, the highest rates of suicide are found among males 15–24 years of age, peaking at 20–25 years of age. The patterns of suicide rates declining after 20–25 years of age and then increasing at 60–65 years of age were found in the US, Canada, and Chuukese, and Marshalles.6,34 The bimodal second spike among the elderly is commonly seen in US and many other nations.5,7,31,35,36 The similar pattern of suicide rates steadily decreasing after 20–25 years of age without a later peak for elderly males was found in New Zealand Maori, Hawaiians, Belauans, Pohnpeans, and Guam.5,22,37 The “Pacific pattern” may reflect the influence of culture. As in Hawaii,5 the steady decline after 40 years of age and the absence of the second smaller spike at 60–65 years of age among Micronesians may be due to the more structured role designations that occur for men, who have a more respected role with age.
Youth suicide is a significant phenomenon among Pacific islanders.5,7 Though time differences exist between Micronesian and current US rates, this comparison is considered valid and useful since current US levels provide a recognized benchmark. Youth suicide in the US has also nearly tripled from 1952–1996, and from 1980–1996 suicide rates among youths 15–19 years of age increased by 14%.38 Similar patterns and trends exist among Micronesian populations. The rate of suicide among youths in Micronesia have remained at epidemic levels for nearly 3 decades and have been reported as being as much as 10–13 times the rates for similarly aged youths in the US and other industrial nations.24,26
Micronesian young men are at significantly greater risk for suicide than are young men of other races and ethnicities. Although men commit suicide more frequently than women in most countries in the world, the differences in rates are usually not so extreme as in Micronesia.5,39 Several factors may help explain the relatively greater risk for suicide among young Micronesian men. First, the traditional status of women in these matrilineal island societies provides women with a much more stable residential and support network than it does men, as men marry and live with women from another village or island.13 Second, family structure and adolescent socialization practices changed in Micronesia following World War II.13 A rapid socioeconomic change or societal transition from traditional to modern creates cultural dislocation for young people. The role changes have undermined adolescent male roles and social supports. The predicament appears to affect the quality of the relationship between parents and their adolescent sons much more than between parents and daughters. Third, young men may face more intergenerational conflicts and pressures than young women.13,26,40 Fourth, young men are at significantly higher risk for substance and alcohol abuse and mental illnesses than young women.13,18,19
Compared with other countries of the world where rapid economic transformation has been taking place, such as China and other Asian or Pacific islands, the suicide patterns in Micronesia are similar in higher youth suicide rates. The author suggests that the youth suicide rates may be affected mostly in countries where the elderly are commonly respected. Female youth suicide may be influenced mostly in traditional patrilineal societies (eg, rural China) and male youth suicide may be mainly affected in traditional matrilineal societies (eg, Micronesia area). Further studies need to explore the assumptions.
The particular form of a suicide method can be culturally determined.41,42 Lethality of hanging may be one reason for high suicide rates of Micronesian men. The lethality of the preferred method (eg, paraquat) may also be one reason for a higher female suicide rate on some Pacific Islands.7,21 The rate of female suicide may be high if women commonly use a highly toxic means (eg, paraquat, pesticide) for suicide, such as in the Fijian islands7 and many other nations (eg, rural China).31
Why did Micronesian studies report much lower prevalence of psychiatric disorders among suicides than other studies in Hawaii, China, the US mainland, and other nations? This may be related to the unstandardized diagnosis process (eg, not using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–Text Revision [DSM-IV-TR],43 or International Classification of Diseases, Tenth Revision [ICD-10]44 criteria) used in Micronesian studies, which may severely underreport the percentage of mental disorders. For example, anger suicide may sometimes be regarded as pathologic using medical diagnosis criteria.20 Diagnoses in most previous studies in Micronesia were based on local mental health office records as well as the author’s own assessment of the individual’s behavior and from interviews with family and acquaintances.13,20 However, the standard DSM-IV-TR and ICD-10 criteria were not used in diagnoses in these Micronesian studies as in other studies.30,31 In a 2007 National Violent Injury Statistics System pilot,45 the results indicated that youths (46%) were less likely than adults (64%) to have had a mental health or substance abuse problems noted in the death investigation reports written by police, medical examiners, or coroners. The lower rates of mental illness among the Micronesian suicides may also be due to the higher percentage of suicide in youths. The lower rate of mental disorders among Micronesian suicides may reflect the influence of cultural factors on suicidal behavior. This may also indicate that the role of mental disorders in suicidal behavior may vary among various ethnic groups. However, further studies need to explore the relationship between suicide and mental disorders in this specific area.
The study was limited in a few ways. First, there is limited literature on suicide, attempted suicide, and suicidal ideation for Pacific Islanders, especially the Micronesian populations. Second, there are relatively few studies and only small samples of cases in specific subgroups (eg, older age group). Third, when comparing existing studies, there is the problem of differing instruments, wording of questionnaires, and time span (eg, lifetime, 1 year, 1 week).5 Many previous studies were based on the available reports or records (eg, hospital and medical records, death certificates, police records and statistics, pertinent church records).9,16 Suicide statistics which are based on death certificates and hospitalization reports may potentially underestimate rates of completed and attempted suicide.5 The degree of underreporting and unreliability of suicide cases in the official reports and publications may be severe.7 Fourth, many cases with mental disorders might not be diagnosed without the standardized instruments and diagnosis criteria (eg, DSM-IV-TR or ICD-10). Given the limitations of previous studies, the basis on which to draw conclusions may be weak.
The suicide phenomenon in Micronesia is unique in cross-cultural comparison, owing to the extremely high incidence among adolescent males; a pattern of extremely high peaks of suicide in young Micronesian Islanders without bimodal distribution; the enormous disproportion of male suicides over female suicides; rapid onset of high suicide rates that occurred in the 1970s, becoming alarmingly high by the 1980s; and the tight cultural patterning in method and motive of suicide. The difference in age distribution may be due to social-cultural influences in family system and role designations for youths, adults, and elders.5 Suicide behaviors among Micronesian populations should be understood in specific culture and acculturation. As there are discordant results in drawing conclusions on the role of ethnicity in suicidal behavior,42 further studies should explore the role of culture in suicide.
Given the limitation of previous studies, various suggestions may be offered for future studies. First, a suicide surveillance system should be set up to monitor the suicidal behavior in this area. Second, more independent research (eg, Psychological Autopsy study, epidemiological survey) on suicidal behavior should be conducted to explore the trend of suicide, especially after 1990, and risk and protective factors of suicide in Micronesia. Third, the impact of ethnicity and culture on suicide should be explored in a deeper way using qualitative and quantitative methods. The effect of social and economic shifts on suicide, especially suicide by male youths, should be explored in detail using longitudinal methods. Fourth, it is crucial to explore the relationship between the mental disorders and suicide in this specific area. The differences between local perceptions and standardized instruments and diagnosis criteria should be investigated. Fifth, standard or comparable instruments and procedures should be used in studies. Sixth, different ethnic groups (eg, Chamorro, Marshallese, Filipino) should be explored separately. Seventh, given the very limited professional personnel (eg, psychiatrist, psychologist, social worker) available in Micronesia, more professionals should be trained. Finally, culturally responsive suicide prevention should be conducted to reduce the suicidal behavior, especially male youth suicide, in this area. PP
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