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The perennial interest in the complex association between pregnancy and suicide is partly fuelled by frequent high-profile media reports about suicide–infanticides in postpartum mothers. However, decades of research on the issue have not produced a coherent narrative. On the one hand, reports about the high rates of prenatal and postpartum depression suggest that suicide (a relatively common outcome of depression) occurs more frequently during pregnancy and the postpartum period than at other times.1 On the basis of these reports, some experts have proposed2 that suicides during the peripartum be classified as direct obstetric deaths in the upcoming International Classification of Diseases (ICD)-11, implying that pregnancy is a risk factor for suicide. On the other hand, some studies3 suggest that female suicide rates are lower during the peripartum period than at other times, suggesting that pregnancy is a protective factor against suicide.

Most studies about this issue have been done in high-income countries, so the systematic review and meta-analysis4 by Daniela Fuhr and colleagues in The Lancet Psychiatry about the association of pregnancy with suicide in low-income and middle-income countries (LMICs) is a useful addition to the literature. Pooling results from 25 studies in 14 LMICs, the authors estimate that 1·00% (95% CI 0·54–1·57) of all deaths during the peripartum period are deaths by suicide; and, based on 29 studies from 17 LMICs, they estimate that 1·68% (1·09–2·37) of peripartum deaths are either suicide or one of four types of

injuries that are often misclassifi ed suicides in adult women (ie, poisoning, falls, burns, and drowning). The authors acknowledge that several factors might limit the validity of these estimates: the included countries were not representative of all LMICs; the implausibly wide range in the two estimated proportions between studies (both measures ranged from 0·00% to 23·08%) suggests major methodological problems in some of the included studies; and various concerns about reporting of suicides—a common problem in all studies of suicide—might result in substantial under-reporting and misclassifi cation of suicide deaths. Some of the cross-national diff erences in the fraction of maternal mortality attributed to suicide might be explained by diff erences in the prevalence of non-suicidal causes of maternal death (which decrease as the medical care for pregnant women in a country improves), in the underlying prevalence of suicide in all women of reproductive age (which varies widely between countries and over time), and in the mean age of childbirth (in most countries suicide rates in women increase with increasing age).

Other than concluding that the quality and com-prehensiveness of death registration during pregnancy and after childbirth in LMICs need to be improved, what do Fuhr and colleagues’ results tell us about the association of pregnancy with suicide? Is pregnancy in LMICs a risk factor for suicide, a protective factor for suicide, or unrelated to the risk of suicide? The estimates provided in the review do not directly address this issue. To be deemed a risk factor (or protective factor) for

Pregnancy and suicide: towards a coherent narrativeSee Articles page 213

misusers, and changes to white matter functioning could maybe happen in older people early on during alcohol misuse, perhaps even after one binge. We live in hope that this change in white matter functioning can be repaired.

Denise Gail CritchlowWarneford Hospital, Warneford Lane, Oxford OX3 7JX, UKgail.critchlow@oxfordhealth.nhs.uk

I declare no competing interests.

1 WHO. Prevalence of alcohol use disorders. http://www.who.int/gho/substance_abuse/burden/alcohol_prevalence/en/ (accessed July 18, 2014).

2 Rosenbloom MJ, O’Reilly A, Sassoon SA, Sullivan EV, Pfeff erbaum A. Persistent cognitive defi cits in community-treated alcoholic men and women volunteering for research: limited contribution from psychiatric comorbidity. J Stud Alcohol 2005; 66: 254–65.

3 de la Monte SM, Kril JJ. Human alcohol-related neuropathology. Acta Neuropathol 2014; 127: 71–90.

4 Lishman WA. Alcohol and the brain. Br J Psychiatry 1990; 156: 635–44.5 Adrian M, Barry SJ. Physical and mental health problems associated with

the use of alcohol and drugs. Subst Use Misuse 2003; 38: 1575–614.6 Sabia S, Elbaz A, Britton A, et al. Alcohol and cognitive decline in early old

age. Neurology 2014; 82: 332–39.7 Thoma RJ, Monnig MA, Lysne PA, et al. Adolescent substance abuse:

the eff ects of alcohol and marijuana on neuropsychological performance. Alcohol Clin Exp Res 2011; 35: 39–46.

8 Pfeff erbaum A, Rosenbloom MJ, Chu W, et al. White matter microstructural recovery with abstinence and decline with relapse in alcohol dependence interacts with normal ageing: a controlled longitudinal DTI Study. Lancet Psychiatry 2014; 1: 202–212.

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suicide, suicide rates in women during the peripartum would need to be higher (or lower) than suicide rates in women of the same ages from the same communities who are not pregnant. None of the included studies provided these data, but the authors did report that the estimated proportions of pregnancy-related deaths attributed to suicide in the WHO Western Pacifi c region and in the Southeast Asia region were much lower than were the proportion of suicides among all deaths of women of reproductive ages in these regions estimated from the Global Burden of Disease data.5 Similar comparisons in the other four WHO regions (Europe, Americas, Africa, and the Eastern Mediterranean) show that the estimated suicide fractions of all mortality in peripartum women were much the same as those in all women of childbearing age. If these results are taken as true, this fi nding indirectly suggests that pregnancy is a protective factor for suicide in LMICs in the Western Pacifi c and Southeast Asian regions and unrelated to the risk of suicide in LMICs in the other four WHO regions. Acknowledging the serious limitations in these estimates, none of the available data from LMICs supports the contention that pregnancy is a risk factor for suicide. Thus the available evidence, although quite sparse, does not support the proposed changes in the ICD-11 that would classify suicides during the peripartum as direct obstetric deaths.

Definitive resolution of this issue will require prospective studies in LMICs that use standardised methods for assessment of the cause of death in large representative cohorts of pregnant women and that compare the mortality profiles in these cohorts with those of age-matched and community-matched cohorts of women who are not pregnant. However, even after resolution of these methodological issues, it is likely that substantial cross-national differences will remain. National and subgroup differences in the contextual factors that mediate the association between pregnancy and suicidal behaviour will probably result in different estimates of the strength (and direction) of the relation between pregnancy and suicide.

Suicide is a complex behaviour that is rarely the result of a one-off life event. The relative importance of biological, social, and psychological factors varies for every suicide but all three types of factors almost always play some part in the causal pathway that

leads to a death by suicide. As is true for divorce, unemployment, death of a family member, and other specifi c life events that have been suggested as risk factors for suicide, the association of pregnancy with the risk of suicide is mediated by the psychological valence the individual attributes to the pregnancy (eg, was it a wanted or unwanted pregnancy?) and by the response of the individual’s social network and of the community at large to the pregnancy (eg, what are the attitudes about the pregnancy of family members and close associates? To what extent does the community support pregnant women and their families?).

Thus pregnancy (and other cardinal life events) can increase, decrease, or be unrelated to the risk of suicide, dependent on the psychological valence of pregnancy, on the types of support networks provided for pregnant women, and on the coincident presence of underlying risk factors for suicide (eg, previous suicide attempt, mental illness, or substance abuse). Within each community these contextual factors will vary between diff erent subgroups of pregnant women based on their marital status, age, educational level, religious affi liation, and socioeconomic status; so comparison of the proportion of pregnancy-related deaths due to suicide between regions or nations provided in this study—even if the methodological issues can be resolved—will not improve our ability to understand or prevent these deaths. The study highlights the need to include suicide and other injuries in the mortality monitoring of pregnant women, but these data are

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A new model of community careCommunity care has been defi ned as a strategy of care that includes the placement of health services in the community; the engagement of the community to help their members who are ill; support of the administration in charge of the community; and the education of community members about health and illness so as to reduce the exclusion of people with mental illness.1–3

When community care was fi rst described, it seemed eminently well suited for the provision of care to people with mental disorders, and with time an increasing number of psychiatrists felt that this was the way of the future. The idea that care in the community would, to a large extent or totally, replace inpatient and other forms of care and thus also eliminate or at least reduce the size and number of large, often stigmatising, mental hospitals was very attractive for humanitarian and economic reasons.

The experience in countries in which the community care strategy was tried has, however, shown that relying mainly or entirely on small mental health units in the community was unsatisfactory for most of those concerned.4–6 The reasons for this are clear but do not seem to be sufficiently convincing because there are still government officials and psychiatrists who repeat the mantra about relying on community care as the only or main form of care for people with mental illness.

First, the communities to which those who created the concept referred rarely existed and their number is diminishing. The proponents of community care saw the community as being defi ned by a geographically restricted territory supported by a fairly independent administrative structure with inhabitants who know each other and are willing to help each other when in need. Rapid urbanisation, the development of informatics (leading to the creation of electronic communities), increased mobility of people in most countries, ethnic tensions, consequences of wars, and other social developments made such communities a rarity.7,8 Many people do not know their neighbours and are not ready to help them. An increasing proportion of people in geographically defi ned territories live alone and people they confi de in are living in other parts of the country or even further away. The administrative structures that govern the use of resources in geographically defi ned territories often have little independence and authority. It is of course possible

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only peripherally related to the prevention of suicide during the peripartum. To prevent maternal suicides other types of research are needed for the identifi cation of subgroups of pregnant women in each community that have higher rates of suicide than in women of childbearing age who are not pregnant, and for then testing diff erent methods for reduction of suicides in these specifi c cohorts of high-risk pregnant women.

Michael R PhillipsSuicide Research and Prevention Center, Shanghai Mental Health Center, Shanghai Jiao Tong University, Shanghai, China; and Departments of Psychiatry and Global Health, Emory University, Atlanta, GA, USA

Preparation of this Comment was supported by the National Natural Science Foundation of China (NSFC, number 81371502). I declare no competing interests.

1 Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health 2005; 8: 77–87.

2 WHO. The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-MM. Geneva: World Health Organization, 2013.

3 Samandari G, Martin SL, Kupper LL, Schiro S, Norwood T, Avery M. Are pregnant and postpartum women: at increased risk for violent death? Suicide and homicide findings from North Carolina. Matern Child Health J 2011; 15: 660–69.

4 Fuhr DC, Calvert C, Ronsmans C, et al. Contribution of suicide and injuries to pregnancy-related mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Psychiatry 2014; published online July 22. http://dx.doi.org/10.1016.S2215-0366(14)70282-2.

5 WHO. Global Health Estimates. 2011. http://www.who.int/healthinfo/global_burden_disease/en/ (accessed Feb 18, 2014).

This online publication has been corrected. The corrected

version fi rst appeared at thelancet.com on July 28, 2014