In our sample, one in three Norwegian patients and one in fourteen Russians reported suicidal ideation at hospital admission. Furthermore, one in seven Norwegians and one in twenty Russians reported having made a suicide attempt. As expected, the figures for the Norwegian patients were somewhat higher than previously estimated among chronic patients [11]. However, they are lower than previously reported among patients admitted for the first time from the same catchment area, where half of all patients had suicidal ideation and one in five had made a suicide attempt [21]. The significantly lower suicidality rates observed in the Russians cohort contrast with much higher suicide rates reported for Archangelsk elsewhere [6, 22]. Lower rates of affective and psychotic disorders, as well as more previous psychiatric treatment in the Russian cohort, may partly explain the difference.

A further factor for consideration is differences in the stigma associated with suicide and suicide-survivorship internationally, which can extend to family, friends, and therapists of those who attempt or complete suicide [33]. Differences in cultural attitudes towards both suicide and mental health problems may contribute to differences in suicide rates across different societies either owing to avoidance of such behaviors or a tendency to under-report them. A study of Russian attitudes reported high levels of suicide related stigma [34] and in a transcultural study of public opinions about psychiatric disorders in Novosibirsk and Germany, it was found that Russian respondents had a stronger tendency to consider mental disorders as self-inflicted and were more inclined to rely on help resources outside the mental health sector, for example traditional “alternative” treatment methods [35, 36]. Such suicide-related stigma is likely to prevent an individual from acknowledging suicidal ideas, and will lessen the likelihood that one communicates the feelings to others, such as family members or mental health professionals.

We found that amongst Russian suicidal ideators there were more women than men. This is consistent with observations that Russian women are more inclined to respond to difficult life conditions with subjective stress [23]. In contrast, men more often respond by engaging in negative health lifestyles and self-destructive behaviors [23], such as alcohol abuse, rather than verbalizing their feelings [37]. Previous studies have reported a strong tendency to somatization both among Russian men and women, as well as high rates of alcohol dependence in Russian men, particularly in rural regions (up to 70 %) [38]. It is possible that a failure to acknowledge and communicate suicidal ideation is in itself a risk factor for completing suicide.

These observations suggest that mental illness and suicide-related stigma in both the assessed patients and the assessors may reduce the degree to which suicidal ideation is acknowledged and identified. A probable under-communication of suicidality might be reduced by using a more comprehensive assessment [39] than the five dichotomous questions used to assess suicidal ideation and attempts in our study. However, we used these questions as they were integrated in the HoNOS questionnaire, which has been used in various previous studies to assess behaviors, impairment, symptoms, and social functioning of severely ill psychiatric patients [28, 29]. In addition, better access to mental health services may further facilitate recognition, earlier diagnosis, and treatment of mental disorders associated with suicidality. Thus, we would expect the accessibility of such services in primary healthcare in Norway to reduce the impact of mental health problems and lead to lower rates of suicidal ideation or attempts. However, our finding of high levels of suicidality in our Norwegian cohort may reflect regional differences in healthcare provision [20].

The role of psychiatric diagnoses was also explored in our study. As predicted, we found greater rates of depressive moods and affective disorders, but lower rates of psychotic disorders, in suicide attempters and ideators than in patients not reporting any suicidality, in both Norwegian and Russian patients. This is unsurprising as the association between suicidality and affective disorders is well known [13, 40]. However, the expected positive association between alcohol/drugs problems and suicidality was only observed in the Norwegian cohort. In contrast to previous findings [10, 41], a negative relationship between alcohol/drug disorders and both suicide attempts and ideation was observed in both univariate and multivariate analyses in our Russian sample. We surmise that the use of alcohol may have different functions in the two societies. In contrast to Russia, Norway has low unemployment rates, good welfare and social security, relatively low levels of mental health stigma, and lower consumption of and social acceptance of alcohol. As such, in Norway alcohol abuse may serve as a prominent factor in suicide attempts, and may signal the presence of suicidal ideation. In contrast, in Russia alcohol may be used as a way to displace or distract from suicidal ideation, serving as a form of ‘chronic suicide’ as described by Menninger [42].

The protective effect of employment observed in the Russian cohort is in line with previous research showing an inverse association between income and various important outcomes, including psychological stress, substance use disorders, suicidal ideation, and suicide attempts [43]. Higher employment rates among the Russian patients and a sparse public social support system in the Russian federation probably contribute to this association. That unemployment did not predict suicidality in the Norwegian cohort, may relate to the fact that fewer of the Norwegian patients were working and substantially more lived on social security.

Our study has several limitations. Some features of suicidal behavior were not assessed, such as familial history of suicide. However, the study is explorative and important factors have been highlighted, although the included list of variables is not exhaustive. Generalization of the findings is limited by the fact that the study only included patients from the northern areas of Norway and Russia. Nonetheless, the use of a cross-cultural comparison allows us to explore how cultural factors may influence relationships of demographic and clinical factors with suicidality. There were small numbers of Russian ideators and attempters in our sample, so results of the statistical analysis should be interpreted with caution. Finally, Russian and Norwegians clinicians may have used some diagnostic criteria differently, particularly concerning personality and adjustment disorders. This should be borne in mind when considering the influence of mental health disorders on suicidality in each cohort.