2.1. Qaujivallianiq Inuusirijauvalauqtunik (“Learning from Lives that have been Lived”)
From 2005 to 2010, a large follow-back study on suicide, an age- and gender-matched case-control study, was conducted among the Inuit of Nunavut by investigating all suicide cases that occurred in the territory between 2003 and 2006 [33
]. Living-controls were selected from the Nunavut Health Care Registration File. For each suicide, the researchers randomly selected a community control that matched on gender and age. The study used two different types of interviews, both using a proxy-based interview procedure to gather information on mental health problems, life events, protective factors, and adversities: First, we used the psychological autopsy method, which consists of interviewing close relatives and/or friends of the deceased, using a combination of open-ended questions and standardized instruments to gather information on the deceased [35
]. Second, we used the life calendar trajectory method, an interview technique in which life events are mapped onto different developmental spheres of an individual’s life trajectory [31
From the initial 240 clinical vignettes completed by the research team for data on mental health problems, 92 suicide cases had sufficient information to analyze the life trajectory. This study reports on the life trajectory of these 92 suicide cases and 92 matched living-controls. The number of informants necessary to complete the interview was determined by the interviewer, based on the quality of the interviews and the amount of information gathered. For this study, 186 interviews were conducted for suicide cases (mean of 2 interviews per case), and 148 interviews for controls (mean of 1.6 interview per case) were carried out. Respondents for the suicide group and controls respectively were parents (54 vs. 42), partners (19 vs. 28), siblings (29 vs. 40), extended family members (43 vs. 15), friends (35 vs. 23), and professionals (6 vs. 0) for the suicide group and controls, respectively. All interviews were conducted in English or Inuktitut, according to the respondent’s preference. Medical charts, coroner’s notes, and criminal records were also systematically reviewed.
The Institutional Research Ethics Board (REB) of the Douglas Mental Health University Institute approved the study, and the Nunavut Research Institute issued a research license. The project was developed in partnership with community organizations in Nunavut, including the regional suicide prevention organization, the Embrace Life Council and Nunavut Tunngavik Incorporated (NTI) [34
]. Results from this study were presented to stakeholders and community members before publication, as required by chapter 9 of the second edition of the Tri-Council Policy Statement: Ethical conduct for Research Involving Humans [36
]. The first author met on numerous occasions with representatives of NTI in Iqaluit, Nunavut, who approved both the results and the language used in the article.
2.2. Life-Trajectory Methodology
The life calendar method was embedded in the larger study [33
]. The current paper focuses on results from the life-trajectory interviews, which investigated the occurrence of life events and the cumulative burden of adversity over the life course. This interview method, which has been described elsewhere [30
], uses a life trajectory calendar to reconstruct the major events of an individual’s life.
The interview uses a narrative approach in order to elicit information relevant to understand the context in which the significant life events occurred. Each life event may be perceived differently and may have different consequences depending on the circumstances in which it takes place. For example, birth, adoption, and marriage may have distinct consequences depending on the culture and the individual contexts in which they occur [37
]. Some events, like custom adoption, which is common in Inuit culture, may have specific consequences for the individual and others in their social environment [38
]. Using a context-sensitive method of inquiry helps establish a distinction between events, especially in light of different cultural norms. The different life spheres discussed during the life-trajectory interview were as follows: circumstances of death (method, motivation, and intoxication by alcohol/drugs); place of residence and housing; experiences during childhood and adolescence; interpersonal and romantic relationships; relations with friends; school and academic experiences; professional experiences; legal problems; family history of suicide and other family adversities; personal difficulties and mental health problems; and mental health services received.
The interviews started with general questions, such as the following: “Could you tell me how (name of case or control) was as a child?” and “Could you tell me about (name’s) school attendance?” Interviewers would then probe further and ask detailed questions to verify if particular events happened or not in specific spheres of the individual’s life course. Each sphere included a number of variables that were important to investigate. Since more than one informant was interviewed, the multiple narrative accounts from different perspectives enriched the information pertaining to the occurrence and the context of each life event. Using this narrative methodology [38
], interviewers sought to accumulate sufficient details about the individual’s life events and its trajectory to allow trained evaluators to assess the key characteristics of each event, for example, duration, severity, and frequency.
2.5. Procedure and Analysis
The first step was to identify and code each event, the age period, and its duration in a graphic calendar. When the interviews with participants were completed, clinical case histories (case vignettes) were drafted with the information obtained from all the measurements and submitted to the panel of evaluators who were independent from the interviewers. The panel was composed of researchers from our team, clinical practitioners, and psychologists who analyzed the life trajectories and established a summary variable identified as the “overall contextual burden of adversity rating” for every 5-year interval of the life trajectory. The evaluators assessed the “contextual burden” of events by assessing their relative weight within the respondent’s developmental circumstances. This conceptualization of contextual burden was borrowed from the morbidity burden or low disease burden approach used to identify the overall morbidity that affects health. It is associated with allostatic load, a concept that links psychosocial stress with the neurobiological and genetic dimensions of mental disorders and suicide. The overall burden assessments ranged from severe (rating of 5 or 6) to moderate (3 or 4) to low (1 or 2). Case reference logs were written and used to maintain the same evaluation across all cases. For all cases, the evaluators coded the burden of adversity for each 5-year period independently before reaching a consensus through discussion. In previous studies from our research group, the intra-pair agreement for each 5-year segment ranged from 76% to 97%; the lowest agreement was found in the 0-to-4-year’s age segment.
The second step was to study the burden of adversity over time. Combined Discrete Time Survival (DTS) and Growth Modeling (GM), using the software Mplus Version 7.4 for Mac [41
], were used to examine the individual variation in burden of adversity within age periods (0–4 years through to 45–49 years) for control and suicide cases in a multigroup analysis. GM can identify distinct sets of continuous growth factors, which are indicated by the intercept, slope, and quadratic term. Suicide is considered as a unique event in time, and in that respect, DTS analysis (generating proportional odds continuous latent variable) was added to the GM. The complete statistical model is illustrated in Figure 1
. The objective of this method of analysis was to examine the pattern of variation and stability over time for each group.
The third step was identifying the presence of cumulative adversity and pathways to suicide. Each life calendar was analyzed individually, and the number of events in each 5-year age period was recorded. Based on clinical vignettes, we organized the data into four different life spheres: (1) early adversity of maltreatment; (2) household and family dysfunction; (3) personal/mental health difficulties; and (4) social difficulties. In each sphere, we grouped a number of variables that were identified by respondents during the interview process. Early adversity of maltreatment included four variables: familial sexual abuse, sexual violence, physical violence, and psychological violence. The sphere of household and family dysfunction included the possible presence of 16 variables: incoherent rules, lack of discipline, lack of supervision, tension with parents, negligence, role reversal, affective distance, family secrets, parental separation, parental divorce, parental mental health difficulties, witnessing parental violence, living with someone who misused alcohol, tension with sibling, food insecurity, and adverse housing conditions. Personal/mental health difficulties included the possible presence of nine variables: Axis I diagnosis (depression, anxiety, gambling, and schizophrenia), alcohol and drug abuse, personality disorder, number of suicide attempts, self-harm, and psychiatric hospitalization. Social difficulties included the possible presence of five variables: conflict with peers, social isolation, bad influence from peers resulting in legal problems, separation or loss of a friend, and difficulty in romantic relationship or commitment.