Young et al. BMC Public Health 2011, 11:874 http://www.biomedcentral.com/1471-2458/11/874 school/workplace ethos, peer-group norms and exposure to risk at the family level. Finally, the ontological level represents individual variation and includes typical psy- chosocial variables such as coping style or capacity for emotional regulation. It should be apparent that while a useful conceptual model, incorporating every ecological level into a single analysis is unfeasible. Nevertheless, the E-TM’s greatest contribution is to emphasise the importance of contextual factors and consideration of the most appropriate ‘level of influence’ relevant to each outcome and lifecourse stage. As a theory the E-TM is open to criticism and can be considered more a ‘conceptual framework’ than a gen- eral theory, because without expert interpretation it can make few specific predictions. For example, in relation to reducing suicide among Native Americans, research- ers using the E-TM suggest that broad-based commu- nity-level interventions might be more effective, because the roots of psychopathology are at the ecological rather than individual-level [28]. They propose that Native American teenagers’ identity - positioned betwixt native and modern cultures - leads to a disrupted sense of social connection and greater risk of suicide, and that strengthening family ties, cultural bonds and native cul- tural practices may reduce such risk. A recent longitudi- nal study used the E-TM to examine the influence of the microsystem (parental, peer and school) on attempted suicide among American adolescents [27], with a particular focus on the interaction between indi- vidual and protective contextual effects such as family, peer and school ‘connectedness’. Somewhat counter to expectation, it found no main effects for school and peer connectedness and only one, rather complicated interaction, interpreted as suggesting that boys who had previously attempted suicide, with poor peer relations, but good school connectedness were at lower than expected risk of further suicide attempts. Thus, the E- TM would predict a protective main effect for parental support, but few significant interactions. A multilevel approach to Durkheim’s theory of suicide The E-TM is a very general framework, but key theories specifically designed to explain suicide explicitly recog- nise the importance of social context. Emile Durkheim proposed an influential and comprehensive contextual theory of suicide. Briefly, Durkheim’s theory proposes two forms of suicide, individually and socially motivated [5]. Durkheim suggested that conventional psychiatric research overestimates individual factors (mental illness and other psychologically orientated explanations) and underestimates societal and contextual influences on suicidality. He focused on the relationship which societal regulation and social integration had with suicide and Page 4 of 15 outlined several types of suicide, but the two most rele- vant and recognised are egoistic, and anomic. Egoistic suicide arises when an individual’s connection to society is fragile, or where circumstances, such as the death of a partner or family break-up, weaken these bonds. Thus, family stability is highly important, but other sources of social connection such as school con- nectedness may offer a buffer against egoistic suicide. Anomic suicide is bound to the concept of ‘anomie’ - a disturbing mismatch between individual and societal norms, values, expectations and aspirations. Durkheim argues that during times of social flux, anomie increases, leading to higher rates of suicide. The degree of anomie will vary between different societies or institutions depending on the ethos promoted; those with a high degree of consensus, connection and integration between individual and social norms and institutions should have lower risks of suicidal behaviours. Schools are one type of institution where the degree of regula- tion and control, school ethos and school connectedness varies systematically. Traditional religion may also pro- vide the shared values and norms that reduce risk of anomic suicide. Since suicide, attempted suicide and self-harm are predicted by many of the same biopsycho- social factors, focusing on more common forms of ‘sui- cidality’ should provide similar (although qualified) insights into the links between context and suicide risk as studies which focus on completed suicide [29]. At least one paper has taken a multi-level approach to youth and suicidality in relation to Durkheim’s theory of suicide [29]. That American study looked at levels of social integration at the neighbourhood level and adjusted for individual background, such as parental supervision and school attachment, with a particular focus on the protective effects of religiosity. An impor- tant finding concerns the cross-level interaction between neighbourhood measures of religiosity and depression on attempted suicide, which indicated that depressed adolescents in secular neighbourhoods are at greater risk of suicide, compared to those in neighbourhoods that are religious. The authors attribute this protective effect to the greater availability of social and emotional support, stronger social bonds and the additional coping mechanisms available in such neighbourhoods that act as a buffer against suicide and depression during ‘turbu- lent adolescence’ when identity and values are formed. While that study is exemplar in its methodological rigour, it is focused on the exosystem level (neighbour- hood) and limited to a single outcome - attempted sui- cide. We extend this approach, using a similar design, but focusing on the microsystem level (school) and incorporating additional measures of suicide risk such as deliberate self-harm and suicidal thoughts or plans. We