Comment on ‘The vulnerability paradox in global mental health and its applicability to suicide’

Michel Dückers et al, present a fascinating paper that aims to confirm an inverse association between country vulnerability and mental health.¹ They cite studies indicating that the higher levels of individualism, more equal distribution of power, low masculinity and greater indulgence within more affluent societies can increase the sensitivity of individuals to social failure and hence increase the risk of suicide. This is a very persuasive argument that harkens back to Émile Durkheim's work on anomie as cause of suicide.² It could be argued that modern technology attacks two presumed protective factors of traditional societies – community and the limited mobility that partially restricts contact to a small group of individuals of similar socioeconomic background. Social media would seem to do this by increasing personal isolation and increasing exposure to a wider network of ‘more successful individuals’ than one would be acutely aware of in a lower-income village. Suicide rates are dropping in some high-income countries but they are increasing in others so, although highly credible, this may not be the entire story.³

However, the papers premise is not fully convincing, the study was only able to include results from upper- and middle-income countries – there was only data from one lower income and as a result the low-income category could not be included in the statistical analysis. Hence the paper explores only upper- and middle-income countries. So, at best the article could argue for the vulnerability paradox in middle- and upper-income countries. There is no reason to project the results on to low-income nations without the data. The reasons for lack of good data on suicide rates from low-income countries is multifactorial but stigma is likely to play a role in addition to lack of resources. Even if data did exist for low-income nations, the much higher mortality rates of lower-income countries from other methods including accidents, homicide and war would make comparison difficult.⁴