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자살예방 통계체계 구축방안 연구

-  최종보고서 -

2018.12.18

고려대학교 의료원 산학협력단

 

제 출 문

국무조정실장 귀하 

본 보고서를 “자살예방 통계체계 구축방안 연구” 용역 최종 보고서로 제출합니다. 

2018.12.18

연구책임자  기  명(고려대학교)

연구원 송인한(연세대학교)

최영철(서울근로자건강센터)

김재영(계명대학교)

김우림(고려대학교)

연구보조원    당지연(고려대학교)

목 차

제1장 연구개요1

제1절 추진배경 및 필요성1

제2절 연구목적 및 내용3

제3절 연구방법4

제2장 자살통계 관리체계 정비6

제1절 국내 자살통계 현황6

제2절 해외 연간 및 자살동향 감시체계 현황10

제 3절 국가자살동향감시 시스템 활용도 제고 방안 및 자살통계 보완 사항26

제3장 자살 연관 통계34

제1절 자살 선행지표의 도출34

제 2절 국가 간 자살연구 비교를 통한 한국 자살예방 연구의 제한성 검토40

제3절 자살예방 다층적 접근의 중요성과 몇 가지 사례들44

제4절 자살 연관통계와 관련 데이터의 활용73

제5절 자살 연관통계의 역할과 정책의 연계에 대한 제안88

제4장 참고문헌90

부록 1. 국내 및 해외 자살 연구 비교의 방법론101

부록 2. 만성질환과 자살의 연관성: 전체질환의 위험도 비교104

부록 3. 호주 Frankston 지역에서 발행하는 시니어 클럽 뉴스레터107

표 차 례

표 1. 사망원인통계 통계과정 개관7

표 2. 경찰통계연보 통계과정 개관9

표 3. 국가별 자살통계 관련 주요내용25

표 4. 현재 자살추정사건 자료 항목29

표 5. 자살 수단 분류29

표 6. 자살사망사건 통계 수집에 사용되는 사망구분표31

표 7. 경찰청 변사 체크리스트 추가 서식33

표 8. 자살의 위험요인 및 국내 데이터를 활용하여 자살과의 연관성 분석 가능여부38

표 9. 국가별 자살 관련 연구 수40

표 10. 연구 디자인별 자살 관련 연구40

표 11. NASP 분류 기준 자살 관련 연구 수42

표 12. 취약계층 대상 자살 관련 연구 수42

표 13. 사회적 관계망 관련 연구53

표 14. 미국 CDC의 자살예방 중재 전략57

표 15. 자살 예방 정책의 확대를 위한 연관 선행지표 및 활용 예시71

표 16. 우선순위 패키지의 예시74

표 17. 지역단위 자살 원인 규명을 위한 자료원75

표 18. 자살관련 단면조사 및 패널조사77

표 19. 연구대상자의 일반적 특성85

표 20. 대분류 단일질환과 자살과의 관계86

그 림 차 례

그림 1. 연구 프레임5

그림 2. 통계청 사망원인통계 수집체계6

그림 3. 경찰청 자살사망자료 수집체계8

그림 4. 기본 패키지와 우선순위 패키지를 이용한 지역별 자살대책계획 수립과정14

그림 5. 호주의 사망통계 수집체계15

그림 6. Cornwall and Isles of Scilly 실시간 감시체계20

그림 7. 지역 기반의 multi- agency suicide prevention group 22

그림 8. 지역별 100,000명당 연령표준화 남성 자살 사망률23

그림 9. 국가자살동향감시 시스템 26

그림 10. 자살의 위기요인35

그림 11. 자살의 위험이 높은 인구집단에서 자살 행동에 대한 보호요인36

그림 12. 자살 행동에 대한 위험요인37

그림 13. General practitioners are treating more and more mental illness46

그림 14. 미국 2005- 2010 압류와 강제철거를 동반한 재정적 문제 관련 자살률의 추이56

그림 15. 노동건강연대 직업에서 노출되는 여러 스트레스들로 인한 기분장애 발생기전59

그림 16. Swedish Registers in Official Statistics82

그림 17. 신경질환 중분류 자살 사망위험도87

그림 18. 3레벨의 자살대책 연동모델89

제 1장 연구개요

제 1절 추진배경 및 필요성

1. 자살 대응의 신속성 제고를 위한 자살동향 감시체계의 필요성

◯ 현재 자살통계는 통계청 사망원인 통계가 거치는 사망원인 검증 등의 일반적인 과정을 거쳐 일 년 주기로 이듬해 9월에 공개되고 있음. 경찰 자살 통계연보 역시 각 경찰관서를 통해 수집된 자료를 연단위로 집계한 자료를 바탕으로 10월경에 공개되고 있음. 

◯ 자살의 특성은 거주지 집중성, 장소 집중성 및 시기 집중성을 보인다고 보고되고 있음. 따라서 특정한 시공간에 자살이 집중되고 이를 예측할 수 있다면 보다 수월하게 자살예방 자원을 동원할 가능성이 높으며 자살 예방의 효율성 역시 높일 수 있음.

◯ 보건 분야의 감염병 발병 감시체계, 교통사고 집계 등은 신속한 정보 수집을 통해 질환과 사고의 확대를 방어하기 위해 즉각적으로 대응하고 있음. 따라서 자살통계 역시 신속하게 수집되어 자살 유행의 양상을 파악하는데 활용될 필요가 있으며, 파악된 양상을 바탕으로 자살예방 단계별 대응 전략을 수립할 필요가 있음. 

2. 다층적 자살예방 정책을 위한 자살 연관통계 활용의 필요성

◯ 자살은 단일원인에 기인하기보다 개인적 요인(정신 및 신체질환, 성, 연령), 사회 관계적 요인(가족관계, 종교, 사회적지지), 경제적 요인(실업, 노동관련, 경제위기)의 복합적 현상으로 설명됨. 자살 예방 정책 역시 우울증 등 자살의 경로에서 근접한 개인적 원인 뿐 아니라 원거리에 위치한 사회적 원인에 대한 접근이 포괄적으로 이루어져야 효율적임. 이는 WHO를 비롯한 각 국의 자살 예방 전략은 자살의 위험 정도에 따라 일반 인구 대상 접근, 선택적 접근, 표적 집단(고위험군)을 향한 접근으로 구분하는 다층적 접근이 핵심을 이루고 있음. 그러나 국내 기존 자살 연구와 정책은 자살 위험요인의 독립적 영향에, 대상의 측면에서 고위험 요인(예. 우울증)에 시기적 측면에서 자살 직전의 상황(예, 자살 수단, 위기 개입(hot line))에 집중하여 왔음. 그러나 자살은 장기적으로 누적된 위기 과정의 중첩으로 이해한다면 자살 고위험군 뿐만 아니라 일반질환자, 일반 채무, 사회적 고립 등 중·저위험군을 포괄하는 자살 예방 연구와 중재 전략 개발이 필요함. 

◯ 다층적 자살예방 정책의 토대가 되는 연구를 위해서는 다양한 위험요인과 취약집단에 대한 특성 연구가 요구됨. 국내 연구는 대체적으로 데이터 규모가 작아 포함되는 자살 건수가 충분하지 않거나, 완료된 자살 대신 자살 생각 혹은 충동 등의 대체변수를 사용하는 경향이 있고, 완료된 자살을 다루더라도 생태학적 연구방법을 적용한 연구가 대다수임. 이러한 한계의 일차적인 원인은 제한적인 기용 가능 데이터의 범위임. 

◯ 현재 활용 가능한 많은 자료의 제한점은 아래의 자살연구의 특성으로부터 기인함:

- 1 -

 자살은 매우 드문 결과변수이기 때문에 대부분의 자살 연구는 대용량 데이터를 필요로 함.

 자살은 한 가지 요인이 아닌 여러 요인으로부터 기인하기 때문에 명확한 원인 규명을 위해서는 광범위한 영역의 데이터를 활용할 필요가 있으며, 많은 경우 다양한 영역의 데이터 연계가 필요함.

◯ 따라서 효과적인 자살예방 연구 진행을 위한 데이터 확보 방안으로는 사망원인 통계와의 결합을 통한 대규모 조사 자료의 활용 또는 기존 자살 연구 데이터의 연계를 제시할 수 있음. 

- 2 -

제 2절 연구목적 및 내용

1. 자살 대응의 신속성 제고를 위한 자살동향 감시체계의 활용도 제고

◯ 현재 통계청과 경찰청은 별도의 과정을 통해 국내 자살통계를 집계하고 있음. 이 연구는 국내외 자살통계 수집 경로를 분석하여 내년 도입 예정인 통계청의 자살동향감시 시스템의 활용도 제고 방안을 제시하고자 함. 이를 위해 다른 국가들의 자살통계 수집과정을 소개하고자 하며, 특히 자살동향 감시체계의 제공을 지역사회가 자살예방에 대한 지원이라는 측면을 강조하여 살펴보고자 함. 

◯ 이외에도 이 연구는 자살통계에 지표로서 포함되는 연령, 주소지, 수단, 원인, 장소 등의 지표들을 검토하고, 추가 및 변경이 필요한 항목을 제시하고자 함. 특히 자살동향 감시체계가 일차적으로 경찰청의 자살데이터를 가공하게 되므로 이 데이터의 항목들을 우선적으로 검토할 것임. 

2. 자살 연관통계 관리의 체계화 및 활용 가능성 제시

◯ 이 연구는 문헌고찰을 통해 국내 및 해외 연구현황을 정리하고 연구영역별로 범주화 및 세분화하여 자살예방 연구를 확대하기 위한 데이터 측면의 인프라를 검토하고자 함. 특히 다양한 자살 위험요인을 파악하고 취약집단에 대한 연구를 진행하기 위해서는 다방면의 데이터를 활용하는 것은 물론 여러 행정자료와의 연계에 대한 고려가 필요한데, 이와 관련한 데이터 수집 가능여부를 확인할 예정임. 이를 바탕으로 이 연구는 자살과 연관성이 높은 선행지표를 제시하고 선제적, 실효적 정책의 대응을 위한 연관통계 활용방안을 제시하고자 함. 

- 3 -

제 3절 연구방법

1. 자살동향 감시체계 조사

◯ 해외 문헌고찰: 국내외 자살통계 구축체계 및 활용내용을 파악하기 위하여 문헌고찰을 바탕으로 일본, 호주, 및 영국의 자살통계 구축체계에 대해 조사함. 해당 국가의 일반적 자살통계의 생성과정, 자살 실시간 감시체계 및 지역통계 제공여부 및 세부내용을 포함한 전반적인 국가 자살통계 시스템에 대해 심층적인 조사를 진행함. 

2. 자살 연관통계의 체계적 제시

◯ 해외 문헌고찰: 자살 연관통계의 선행지표들을 체계적으로 제시하고, 그 활용 가능성을 제시하기 위해 국내외 자살 연구현황 파악하고자 함. 한국, 일본 및 스웨덴의 자살연구에 대한 문헌고찰을 진행함. 자살 관련 연구영역의 주제를 분류하고 세분화하여 이를 선행지표로서 정리하고, 한국 자살 연구에서 미흡하게 다루어지는 영역을 발견하고자 함. 검색 엔진으로는 Pubmed를 이용하였으며, 조사 대상은 2000- 2018년에 게재된 commentary, letter, meta- analysis 및 systematic review를 제외한 문헌으로 정의함. 특히 결과변수가 완료된 자살(completed suicide) 혹은 자살 사망인 연구를 추출하였음. 논문 분류는 스웨덴의 National Centre for Suicide Research(NASP)에서 발표한 자살 연구 분류를 활용함(NASP, 2014).

◯ 중요 선행지표에 대한 연구고찰: 자살예방의 영역 중 보건복지, 사회 및 노동 분야 몇 가지 영역의 해외 연구와 정책 사례를 이와 관련된 국내 연구 혹은 정책의 한계점을 제시함. 이를 통해 사회 및 노동과 같은 영역이 어떻게 자살예방과 결합될 수 있는지, 이들 영역에서 자살과 연관성이 있는 의미 있는 선행지표를 보여주고자 함. 

◯ 데이터 분석: 위의 과정을 거쳐 파악된 의미 있는 선행지표 중 그간 간과되었으며, 데이터 활용의 측면에서 의미 있는 선행지표(이 경우 일반적 질환)를 선정하여 자살 위험도에 대해 직접 통계분석을 진행함. 구체적으로  국민건강보험공단 맞춤형 자료를 자료원으로 사용하였으며, 분석방법으로는 카이제곱 검정(Chi- square test), 분산분석(Analysis of Variance, ANOVA), t- test, 로지스틱 회귀분석(Logistic regression analysis) 및 generalized estimating equation(GEE)을 적용함. 모든 통계분석은 SAS software version 9.4(SAS Institute, Cary, NC, USA)를 이용함. 

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◯ 연구 프레임<그림 1>:

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제 2장 자살통계 관리체계 정비

제 1절 국내 자살통계 현황

1. 통계청 사망원인통계(통계청, 2017)

◯ 통계청 사망원인통계의 사망신고자료 수집체계는 아래와 같음<그림 2>:

 사망신고서를 접수받은 시·구 또는 읍·면·동의 담당공무원이 신고서 내용을 인구통태시스템에 입력

 입력이 완료된 신고서는 입력기관에서 1년간 보관 후 폐기

 취합된 전산자료는 내용 검토 및 확인 후 집계

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◯ 통계청 사망원인통계의 통계 작성과정은 아래와 같음<표 1>:

◯ 통계청 사망원인통계의 작성방법 및 작성항목은 아래와 같음:

 인구동향조사를 통해 지방자치단체에서 입수된 사망신고서 및 사망진단서를 이용하여 통계 작성

 사망신고는 기준연도 1월부터 다음해 4월까지 접수된 신고서 중 기준연도 사망자를 대상으로 작성하고, 10년 단위로 지연 신고분을 반영하는 시계열 정비 실시

 접수된 사망신고서 및 사망진단서의 사망원인을 검토하여 한국표준질병사인분류(KCD) 기준으로 분류하고, 세계보건기구(WHO)의 국제표준질병사인분류(International Classification of Diseases, ICD)에서 권고하는 제표형태로 원사인을 집계하여 통계 작성. 

 통계 작성 과정에서 보다 정확한 산출을 위해 의사 사망진단서와 경찰청 사건수사자료 등을 참고

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 통계 작성은 사망신고서 서식에 근거하며, 주요 작성항목에는 주민등록번호, 성별, 주소(주민등록지 기준), 사망 일시, 사망 장소, 사망 원인, 사망 종류, 진단자, 국적, 교육수준, 직업 및 혼인상태가 포함됨

 부정확한 사인 및 사망의 외부요인(사고사 등)에 의한 사망은 국립암센터, 건강보험공단, 국립과학수사연구소, 경찰청, 국방부, 해양경비안전본부 등의 기타 행장자료를 이용하여 보완

2. 경찰청 경찰통계연보(경찰청, 2016)

◯ 사건수사, 범죄 통계 및 분석, 수사지식정보, 형사사법정보망 등이 통합된 범죄정보관리시스템(Crime Information Management System, CIMS)을 통해 경찰의 범죄통계가 산출됨.

◯ 경찰청 경찰통계연보의 자살사망자료 수집체계는 아래와 같음<그림 3>:

 변시 사건의 일반적인 처리절차는 ①변사체 신고 및 변사체 발생보고, ②검사의 변사사건 지휘, ③변사자 검시·검안절차, ④수사의 개시와 검증영장 청구, ⑤부검 및 검증조서의 작성, ⑥시체의 인도, ⑦검사의 처분 및 변사사건 종결 단계를 거침(김진영, 2016)

 이 과정에서 수사업무를 담당하는 경찰공무원은 변사사건에 대한 내용을 경찰의 형사사법정보시스템(Korea Information System of Criminal Justice Services, KICS)에 입력

 변사 사건의 경우, 부검 등을 통해 타살 혹은 자살의 여부를 최종 판단할 수 있음. 따라서 사건발생 초기에는 초동수사의 결과를 입력하고(매월), 이후 각종 검사결과 등을 참조하여 전년도 변사사건(자살)에 대한 최종 수사결과를 작성 및 입력(9월~10월)

 경찰청 수사국장은 각 경찰관서에서 형사사법정보시스템에 입력한 자료를 집계하여 관리

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◯ 경찰청 경찰통계연보의 통계작성 과정은 아래와 같음<표 2>:

◯ 경찰청 경찰통계연보의 통계 작성방법 및 작성항목은 아래와 같음:

 경찰통계연보는 CIMS를 바탕으로 각 경찰관서에서 입력한 자살사망자의 정보를 토대로 작성

 경찰 변사자통계자료는 사망자의 성별, 생년월일, 발견 장소 및 일시, 사망추정일시, 사망구분, 사망수단, 자살형태, 타살형태 및 사건개요에 대한 정보를 담고 있음(임정수 외 2008). 

 이후 범죄통계발생원표의 서식에 근거하여 연도별, 원인별 자살자 현황, 자살자 연령대별 근황, 자살 원인 및 수단별 현황 등에 대한 정보가 다음과 같이 경찰통계연보에 포함됨.

 연도별 원인별 자살자 현황: 가정문제, 경제생활문제, 남녀문제, 사별문제, 육체적 질병 문제, 정신적/정신과적 문제, 직장 또는 업무상의 문제, 학대 또는 폭력문제, 기타, 미상

 자살자 연령대별 현황: 직업(농·임·수산업, 자영업, 전문직, 공무원, 일반봉급자, 유흥업종사자, 일용노동자, 기타 피고용자, 무직자, 기타), 학력[미취학, 초교(재, 중, 졸), 중교(재, 중, 졸), 고교(재, 중, 졸), 대학(재, 중, 졸), 대학원(재, 중, 졸), 미상] 및 연령(10세 미만, 10~20세, 21~30세, 31~40세, 41~50세, 51~60세, 61세 이상, 미상)

 자살 원인 및 수단별 현황: 목맴, 익사, 도검, 총포, 폭발물, 음독, 기차, 자동차, 가스중독사, 추락, 소사, 전기, 기타

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제 2절 해외 국가 및 자살동향 감시체계 현황

1. 일본

가. 국가 자살예방 계획의 개요와 자살통계 일반 

◯ 일본의 자살대책계획은 2006년 자살대책기본법 제정 이후 크게 발전된 것으로 평가됨. 국가적으로 종합적인 자살대책을 추진한 결과 자살이 개인의 문제가 아닌 사회의 문제로 인식 될 수 있었고 연간 자살자 수 역시 지난 10년간 약 23% 감소하는 추세를 보임(Motohashi et al. 2017). 이후 ‘누구도 자살로 내몰리지 않는 사회’를 실현하는데 있어서 보다 종합적이고 효과적인 정책을 시행하기 위해 2017년 새로운 자살종합대책(General Principles of Suicide Prevention Policy)이 발표되었으며, 관련 업무는 후생노동성 산하의 자살대책추진본부(Japan Support Center for Suicide Countermeasures, JSSC)가 담당함(JSSC, 2017). 구체적으로 자살종합대책의 기본 방침은 다음과 같음(JSSC, 2017):

 삶을 위한 포괄적인 지원: 삶의 저해요인(자살 위험요인)은 감소시키는 반면 삶의 촉진요인(자살 보호요인)은 향상시켜 삶을 위한 포괄적인 지원을 추진

 자살예방과 관련된 여러 관점의 정책 연계를 통한 종합적인 대책 마련: 정신보건학적, 사회경제적 관점 등을 포함한 여러 시각에서 정책을 수립하고, 특히 기초생활수급자 자립지원제도 등과의 연계를 통해 모두가 정신보건의료 서비스를 받을 수 있도록 추진

 개인, 지역 및 사회제도 수준에서의 자살대책 추진 및 연동(Three Level Model of Interconnecting Suicide Countermeasures): 개인지원 수준에서는 개개인의 문제 해결을 위한 상담진행 지원에 초점을 두고, 지역연계 수준에서는 보다 포괄적인 지원을 위한 여러 관계기관의 연계를 목표로 하고, 사회제도 레벨에서는 법, 계획, 체제 등의 틀을 구성하면서 개인, 지역 및 사회제도 수준 간의 유기적 연동에 의한 종합적인 자살대책을 추진

 인식개선 및 자살예방을 위한 실천사항 추진: 국민의 자살에 대한 이해도를 높이고 자살위기에 직면할 경우 도움을 요청해야한다는 인식이 보편화되도록 노력함과 동시에, 자살과 정신질환에 대한 편견을 바로잡을 수 있도록 지원하며 대중매체의 자살보도를 검열

 자살대책 관련기관의 역할 명확화 및 기관 간의 협동: 정부, 지방공공단체, 관계기관, 민간단체, 기업, 국민 등의 역할을 명시하고 이들 간의 상호연계 및 협동 추진

◯ 일본의 자살통계는 일본 경찰청(National Police Agency)의 자살통계와 후생노동성(Ministry of Health, Labor, and Welfare, MHLW)의 자살사망통계로 구성됨. 일본 경찰청과 후생노동성의 통계 간에는 다음과 같은 차이가 있음(일본 경찰청, 2018):

 조사대상:

­ 경찰청 자살통계: 일본에서 거주하는 외국인을 포함한 총 인구 

­ 후생노동성 자살사망통계: 내국인

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 자살 발생 지역 계상 기준:

­ 경찰청 자살통계: 시체 발견 지역 기준 

­ 후생노동성 자살사망통계: 주소지 기준

 조사방법:

­ 경찰청 자살통계: 수사 등으로 자살이라고 판명된 시점에서 자살 통계표를 작성한 후 계상

­ 후생노동성 자살사망통계: 자살, 타살 또는 사고사 중 사망원인이 불명확한 경우 자살통계에 포함되지 않으며, 이후 사망진단서에 사망원인이 자살로 정정되는 경우에만 계상

◯ 경찰청의 자살통계는 경찰청 생활안전국과 각 도도부현의 경찰 본부에서 파악하고 있는 자살 사례를 바탕으로 전국 자살 건수를 집계한 자료이며, 이는 월별로 조사되고 있음(경찰청, 2018). 아래는 나라현 경찰본부의 자살통계 작성 과정을 간략하게 설명함(나라현 경찰본부):

 사체의 사인이 자살로 판단될 시 담당 경찰관은 “자살통계 원표 기입요령”에 근거하여 자살통계원표를 작성함.

 작성된 원표를 심사하는 심사책임자(어린이·여성·고령자안전대책과 자살통계 담당자 보좌 혹은 경찰서 형사과장)는 원표의 각 항목에 대하여 기재 내용의 오류, 기입 누락 또는 모순을 검사하고 이를 생활안전과장에게 인계함.

 생활안전과장은 원표를 인수 받은 후 매월 원표를 정리해 이를 다음달 5일까지 어린이·여성·고령자안전대책과에 송부함.

 어린이·여성·고령자안전대책과의 심사책임자는 형사부 수사과의 협력을 얻어 원표의 기재내용을 상세하게 심사한 후, 원표와 관련정보를 최종적으로 경찰청 생활안전국에 보고함. 또한 어린이·여성·고령자안전대책과 과장은 심사가 종료된 원표를 바탕으로 자살통계자료를 작성할 수 있음.

◯ 경찰청의 자살통계는 이후 후생노동성 산하의 자살대책추진본부(JSSC)에 전달됨. JSSC의 구성 부서는 다음과 같음:

 Office for Suicide Data Analysis: Actual local suicide conditions profile 작성, 지역 자살통계 구축 및 갱신

 Office for Comprehensive Suicide Countermeasures: 지역자살대책 정책 패키지 구축 및 갱신

 Office for Promotion of Support for Suicide Survivors: 자살 시도자 및 유가족 지원 추진

 Office for Promotion of Community Suicide Policy: 각 지역(도도부현)의 지역자살대책추진센터 지원

◯ 후생노동성의 자살사망통계는 인구동태통계를 기반으로 작성되며, 인구동태통계에 사망원인이 자살로 명시된 건수에 대해서 시계열 분석 등을 실시한 자료임. 발표되는 자료로는 

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조사 다음 달에 제공되는 신속 월별자료(Prompt Vital Statistics Report), 조사 5개월 후 제공되는 월별자료(Monthly Vital Statistics Report) 및 이를 최종 수정·보완한 연간자료(Annual Vital Statistics Report)가 있음.

나. 자살동향 감시를 위한 단기 자살통계 

◯ JSSC는 자살통계 집계·분석 후 조사 다음 달에 월별 수치 및 잠정치를 발표하며, 이를 바탕으로 일본의 최신 자살 동태에 대한 파악이 가능함. 또한, 해당 년도의 확정된 최종 자살통계는 다음해 3월에 공표됨. 자살통계에서 제공되는 변수는 다음과 같음(일본 경찰청, 2018; JSSC, 2018):

 성별

 연령

 동기/원인

 자살 시점(월)

 지역

 자살 장소

 직업

 거주형태

다. 지역 자살예방대책에서의 자살통계 활용

◯ 일본 자살종합대책의 핵심 요소 중 하나는 JSSC의 주도 하에 모든 도도부현 및 시정촌이 지역계획을 수립하는 것임. 따라서 자살종합대책은 국가의 기본 방침과 더불어 지역별 자살대책계획의 수립을 추진함. 이는 일본의 지역별 자살률 격차가 높기 때문인데, 특히 북부 지역의 자살률이 높은 것으로 파악됨. 따라서 정부는 지역 특성을 반영한 효율적인 지역자살대책의 계획 및 운영을 지원하고 있음(JSSC, 2018). 

◯ 도도부현은 지역자살대책계획을 수립하고 지역자살대책추진센터를 기반으로 시정촌을 지원함. 또한 정신보건복지센터 운영하며 자살관련 캠페인을 진행하고, 자살시도자 및 유가족지원 체제를 정비하는 등의 역할을 맡음. 시정촌은 도도부현과의 연계를 통해 주민의 생활에 밀착된 캠페인을 시행하고 상담 지원을 하는 등, 지역 특성을 반영한 자살대책사업 추진의 중심적 역학을 담당함. 또한 시정촌은 이 과정에서 보건, 의료, 복지, 교육, 노동 및 그 외의 여러 관계 부서와 협력하며 책임자는 시정촌장 혹은 부시정촌장으로 지정함. 후생노동성은 JSSC를 통해 지역별 사업을 재정적으로 지원하고 구체적인 사업목표를 제시한 후, 각 지역으로부터 결과보고를 받음. 

◯ 지역 통계 구축 및 갱신 관련 업무 역시 JSSC의 자살실태·통계분석실(Office for Suicide 

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Data Analysis)에서 담당하는데, JSSC의 자살실태·통계분석실은 지역 간 비교가 가능할 수 있도록 동일한 연구방법론을 적용하여 자살관련 데이터를 분석하며, 이를 바탕으로 지역 자살대책계획에 활용이 가능한 “actual local suicide conditions profile”을 작성함(JSSC, 2018). 해당 프로파일은 경찰청 및 후생노동성의 자살통계를 포함한 여러 데이터, 예를 들어 National Census, Vital statistics, corporate and economic statistics, Comprehensive Survey of Living Conditions, Survey on Time Use and Leisure Activities 등을 기반으로 작성됨(JSSC, 2018). 이 프로파일은 전국대비 해당 지역의 자살률을 제시하는 것은 물론, 각 지역별로 자살률이 높은 군이 공유하는 특성(성별, 연령 및 고용상태) 등을 포함한 다양한 통계를 제공함으로서 각 도도부현 및 시정촌이 이를 이용하여 각 지역의 자살 현황을 이해하고 지역 자살대책계획을 개발할 수 있도록 함. 기본적으로 조사되는 변수는 일본의 국가통계와 동일함(JSSC, 2018).

◯ 일본의 지역별 자살대책계획의 핵심 요소는 지역별 자살통계 관련 특성을 담고 있는 “actual local suicide conditions profile”을 기반으로 작성된 “local suicide countermeasure policy package”인 것을 확인할 수 있음. Local suicide countermeasure policy package는 기본 패키지(basic package)와 우선순위 패키지(priority package)로 구성되어 있음. 기본 패키지는 자살예방을 위해 모든 지역에서 시행되어야하는 국가 지정 최소 수준의 정책이며 이의 구성요소는 다음과 같음(JSSC, 2018):

 지역 현지 네트워크 강화: 주정부, 지방공공단체, 관련 기관, 민간 기관, 기업 및 주민 간의 네트워크 강화를 위한 구조 형성

 자살대책계획에 필요한 인적 자원 양성: 다양한 종류의 고통이나 어려움을 겪고 있는 사람들을 조기에 인식하고 발견할 수 있도록 관련 인적 자원 양성

 주민들의 자살 관련 인식 및 지식 증진: 자살이라는 궁지에 내몰리는 것은 누구에게나 일어날 수 있는 위기이며 그러한 경우 도움을 요청해야한다는 지역 전체의 공통 인식 개선

 삶을 위한 포괄적인 지원: 삶의 저해 요인(자살 위험요인) 감소, 자살 시도자 및 유가족 지원 등을 포함한 삶의 촉진요인(자살 보호요인) 향상

 청소년 대상 “SOS를 요청하는 방법” 관련 교육 추진: 학생들이 어려움에 직면할 경우 도움을 요청할 수 있도록 학교에서 지역보건간호사 혹은 지역 전문가 등과 협력하여 관련 교육 추진

◯ 우선순위 패키지는 지역별 자살 관련 특성이 상이한 것을 고려하였을 때, 각 지역에서 보다 효과적인 자살대책계획을 수립할 수 있도록 추가적으로 시행할 수 있는 정책임. 각 지역은 분석된 ‘actual local suicide conditions profile’을 바탕으로 필요한 우선순위 패키지 정책을 선정 및 적용함. 구체적으로 우선순위 패키지는 다음의 8가지 항목으로 구성되어 있음(JSSC, 2018):

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 아동과 청소년, 업무 관련 문제, 사회적 약자, 실직자, 노인, 고위험 지역, 지진의 영향을 받은 지역 및 자살 방법

 예) 아동과 청소년: 따돌림 피해자 아동의 자살 예방/ 학생지원 강화/ 경제적 어려움을 겪는 학생에 대한 지원 강화/ 정보통신기술을 활용하여 아동청소년 아웃리치 강화/ 아동청소년을 대상으로 상담 방법 교육/ 사회전체의 아동청소년 자살률 감소를 위한 전략 구상

◯ 각 지역은 기본 패키지와 우선순위 패키지를 결합하여 지역 상황에 적합한 자살대책계획을 수립 및 시행함<그림 4>. 

2. 호주

가. 국가 자살통계

◯ 호주의 자살통계는 공식적으로 2009년부터 통계청(Australian Bureau of Statistics, ABS)의 사망원인통계(cause- of- death data)를 통해 보고되고 있음. 사망원인통계는 크게 National Coroners Information System(NCIS)와 Registar of Births, Deaths, and Marriages의 자료를 기반으로 작성되는데, NCIS 자료의 경우 각 주(state)와 지역(territory)에 배치되어 있는 검사관들이 입력하는 자살을 포함한 다양한 사망 관련 정보를 포함하고 있음(De Leo et al, 2010). 호주에서는 사망이 갑작스럽거나 예기치 않은 것으로 의심될 경우 법적으로 검시관의 조사를 요하며, 검시관들은 사망자 신분, 사망 장소 및 시간, 사망 원인 등을 기록함

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(Sutherland et al, 2017). 2000년 7월부터 발생한 모든 사망 관련 자료는 NCIS 데이터베이스에 기록되며, ABS가 발표하는 자료는 최종적으로 오류 수정 등을 거친 자료임 (De Leo et al, 2010). 

◯ 하지만 구체적으로 사망원인통계 작성 과정을 살펴보면, NCIS 및 Registar of Births, Deaths, and Marriages 자료 구축 시 경찰 조사, 주 및 지역 등록 자료, 의사 소견서, 법의학 및 부검 자료 등이 여러 경로에서 활용되고 있어 일정한 사망통계 수집체계가 없고, 이로 인해 통계 간의 불일치 가능성이 존재함<그림 5>. 특히 ABS 사망원인통계의 경우, 자살 사망이 과소 추정되는 경향이 보임(De Leo et al, 2010). 지역별 검시체계가 상이하여 야기되는 문제를 해결하기 위해서 ABS와 National Committee for Standardized Reporting of Suicide(NCSRS)는 동일한 사망신고서 사용 및 체계적인 코딩을 장려하는 등 지역 간 자료 편차를 감소시키기 위해 지속적으로 노력하고 있음 (Suicide Prevention Australia, 2014). 

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◯ 자살 데이터 감시체계의 질 향상은 자살예방 관련한 정책 중 국가 우선순위로 명시되었으며 특히 현재 시스템에서는 국가 최종 사망통계가 공표되기까지 약 2년이 소요되므로 이와 관련된 개선이 요구되고 있음(National Mental Health Commission, 2013). 

나. 자살동향 감시체계

◯ 호주의 공식 국가 및 지역 자살 통계는 ABS에서 발표되지만, 호주의 사망원인통계 작성 과정에서 각 지역의 검시자료가 활용되므로 호주의 모든 주와 지역은 자체 감시체계(surveillance system)를 갖추고 있거나 구축 예정에 있음. 특히 Queensland와 Victoria 주는 종합적인 지역 자살 레지스트리(registry)인 Queensland Suicide Register(QSR)와 Victoria Suicide Register(VSR)를 관리하고 있음. 

 Queensland Suicide Register는 국제적으로 알려진 자살 사망 수집 시스템으로, 1990년부터 Queensland 주에서 발생한 모든 자살 건수에 대한 관련 자료를 포함하고 있으며 해당 자료를 활용하여 관련자들은 보다 빠르게 자살 양상에 대해 파악할 수 있음. 운영은 호주의 자살예방 연구센터인 Australian Institute for Suicide Research and Prevention(AISRAP)에서 담당하고 있으며, 자살 통계는 공식적으로 연간 3회 발표됨. 포함되는 변수로는 일반적인 인구학적 특성, 자살 정황, 사망자 일생 사건(life event), 정신과 진료 기록 등이 있음. 구체적으로 QSR 시스템은 경찰 보고(Form 1 Police report) 바탕 검시 자료, 검시관 보고, 부검자료 및 독극물 보고(toxicology report)를 바탕으로 자살 의심 케이스 자료를 수집함. 이후 QSR은 모든 자살 의심 케이스를 beyond reasonable doubt, probable, possible, unlikely로 분류함. 이외에도 AISRAP는 자료 수집 주기를 단축하기 위해 interim Queensland Suicide Register(iQSR)을 운영하고 있음. 하지만 iQSR의 경우 검시관에게 일차적으로 보고되는 경찰 조사(Form 1 Police Report)만을 바탕으로 자료 구축이 되므로, 자료의 질적 편차가 크며 사망자의 기본적인 인구학적 변수만이 조사됨. 이후 정보 추가 및 오류 수정 등을 거쳐 해당 자료는 QSR에 업로드됨. Queensland 정부는 iQSR을 활용하여 빠르게 최근 자살 건수에 대해 조사하고, 이후 QSR 자료를 이용하여 사망자에 대해 보다 정확하고 구체적으로 파악하고자 함(Queensland Government Mental Health Commission, 2015). 

 Victoria Suicide Register는 2014년부터 Victoria 주에서 발생한 모든 자살 건수에 대한 관련 자료를 조사하며, 운영은 Coroners Court of Victoria가 담당하고 있음. 검시관에 의해 자살로 의심되는 모든 사망 케이스는 48시간 내에 VSR에 보고되고 있으며, 연구 결과 이중 약 96%가 실제 자살 사망 케이스인 것으로 파악됨. 이 자료는 사망자의 성별, 연령, 자살 방법 및 장소에 대한 기록만 포함하고 있으며, 이후 정보가 추가된 최종 자료는 약 12개월 후 발표됨. VSR은 성별, 연령, 원주민(Aboriginal or Torres Strait Islander) 여부, 성소수자 여부, 타 문화 혹은 타 언어 사용 여부, 직업 상태 및 결혼 관련 변수를 포함함. 현재 VSR과 

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ABS 자료의 일치도는 매우 높은 것으로 보고되고 있음. 자료 접근은 Coroners Court of Victoria로부터의 승인을 요구함(Sutherland et al, 2017).

◯ QSR과 VSR 구축 사례를 바탕으로 South Australia, Western Australia 및 Tasmania 지역은 지역 자살 레지스트리 구축을 목표로 하고 있으며, New South Wales 및 Northern Territory 지역은 자료 수집 주기를 단축시키고 질을 향상시켜 지역 감시체계를 발전시킬 예정임(Government of South Australia, 2018; Government of Western Australia Mental Health Commission, 2018; Tasmanian Government, 2016; New South Wales Government Mental Health Commission, 2018; Northern Territory Government, 2018). 

다. 지역 자살예방대책에서의 자살통계 활용

◯ 호주는 국가적으로 자살예방전략(National Suicide Prevention Strategy, NSPS)을 시행하고 있으며, 호주의 모든 주와 지역은 기본적으로 ABS의 사망원인통계를 활용하여 지역 자살예방대책을 계획함. 또한 Queensland와 Victoria 주처럼 지역 감시체계가 있는 지역도 일정한 주기별로 ABS 데이터를 사용하여 자체 데이터의 오류 및 누락 등을 보완함. 

◯ 지역별 자살통계의 활용방법과 관련해서는, Queensland 지역 정부는 자살 동향을 모니터링 및 지역 자살 위험요인 파악에 QSR을 활용하고 있으며, 이를 통해 보다 적절한 자살예방 정책을 시행하고자 함. 지역 정부는 QSR을 통해 지역 자살 의심(beyond reasonable doubt, probable 혹은 possible 분류 케이스) 건수 및 관련 사항에 대해 상세하게 파악하고 있음. 따라서 QSR은 지역 맞춤 자살예방대책에 필요한 기본 자료를 제공하고 있음. 구체적으로 기록 및 분석되는 변수는 다음과 같음(Potts et al, 2016) :

 성별

 연령

 지역: metropolitan, regional, remote 

 소수자 여부: Aboriginal and Torres Strait Islander peoples

 자살 방법: hanging and strangulation, carbon monoxide and other gases, poisoning by solid and liquid substances(analgesics, antipyretics and antirheumatics, barbiturates, tranquilizers and other psychotropic agents, other sedataives and hypnotics, multiple drug toxicity, other and unspecified drugs, other and unspecified solid or liquid poisons), firearms and explosives, jumping from high places, drowning, hit by a moving object, suffocation by a plastic bag, cutting and piercing, burns and fire, crashing of a motor vehicle, gases in domestic use, electrocution, other and unspecified methods

 결혼 및 취업 상태

 정신질환 및 관련 치료 여부

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 자살 원인: relationship problems(conflict and separation), financial problems, pending legal matters, recent or pending unemployment, work and school related problems, recent bereavement, child custody dispute, childhood trauma, sexual abuse

 신체 질환 여부

◯ Victoria 지역 정부 역시 VSR을 QSR과 비슷하게 활용하고 있음. VSR은 지역 단위의 자살 감시체계로 지역 정부는 이를 활용하여 Victoria 지역에서 발생하는 모든 자살 건수를 파악하고 관련 정보를 수집하여 자살 동향 및 특징을 모니터링하고 있음. 수집되는 정보는 QSR과 전반적으로 비슷하나, VSR은 추가적으로 자살 위험이 높은 것으로 파악되는 성 소수자(gay, lesbian, bisexual, transsexual and intersex, GLBTI) 여부를 기록하고 있음(Sutherland et al, 2017).

3. 영국(England)

가. 국가 자살통계의 생산과 활용

◯ 영국의 국가 자살통계는 국가통계청(Office for National Statistics, ONS)의 사망통계와 Public Health England(PHE)의 Suicide Prevention Profile(Suicide Prevention Fingertips Tool)로 구성됨. ONS에서 제공하는 통계는 1981년부터 가장 최근까지의 자살자 데이터를 기록하고 있음. ONS의 사망통계는 의사 혹은 검시관이 작성하는 사망신고서를 바탕으로 산출되며 매년 정기적으로 발표됨. 자살 사망이 등록되기 위해서는 해당 지역에서 검시 조사가 완료되어야하며, 이는 몇 달에서 몇 년까지 소요되므로 등록에 지체가 생길 가능성이 있음. 기록되는 모든 사망 건수에는 medical certificate of cause of death(MCCD), 사망 원인, 개인정보 등의 정보가 추가됨(ONS, 2015). 

◯ PHE의 Suicide Prevention Profile은 ONS, 지방 정부 당국, 지방 자치청, Clinical Commissioning Groups(CCGs) 등으로부터 제공 받은 자료를 기반으로 지역별 자살 관련 통계를 발표함. 자살률은 ONS의 자료를 기반으로 하며, 포함되는 자살 관련 변수로는 자살 위험요인 발생률(알코올로 인한 입원, 가정 폭력, 노숙, 실업, 주관적 건강상태), 정신과를 포함한 다방면의 의료서비스 이용률 등이 있음. 하지만 각 변수를 파악하기 위해 여러 자료를 사용하고 있어 항목별 신뢰도가 상이하며 이는 변수의 질 순위(quality rank)를 통해 확인 가능함(PHE, 2016a). PHE의 Suicide Prevention Profile을 활용할 시 지역별 자살률 비교가 가능함. 또한, 각 지역의 고위험군(high- risk groups)을 파악하고 정신과 및 National Health Service(NHS) 의료이용률 등을 확인할 수 있음. 따라서 인구 수, 지역 박탈지수 등이 유사한 지역끼리의 벤치마킹이 가능함(PHE, 2016a).

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◯ 특히 영국의 각 지역은 ONS 사망통계를 포함한 여러 자살 관련 자료를 활용하여 지역별 자살예방 계획을 수립함. 예를 들어 런던(City of London)시는 자살 동향 파악을 위해 ONS 사망통계, PHE 관련 통계를 사용함과 동시에 검시자료를 수집함. 또한, 런던 경찰청은 자살 시도자 발견 시 시도자가 정신 질환을 앓고 있거나 치료가 필요한 것으로 판단되는 경우 관련 정보를 제공할 수 있음. 이러한 다방면의 자료 활용을 통해 각 지역은 구체적인 자살예방대책 시행 계획(action plan)을 세우고 진행사항 및 성과를 모니터링 함(City of London Corporation & City of London Police, 2016). 

나. 자살동향 감시체계

◯ 이외에도 PHE는 각 지역이 데이터를 모니터링하고 자살 추세 및 ‘hot spot’을 신속하게 파악하기 위한 실시간 감시체계(real time surveillance)의 시범사업을 특정 지역에서 진행하고 있음. 실시간 감시체계를 도입할 경우 해당 지역의 공중보건 팀(public health team, PH) 혹은 자살예방 그룹(Multi- agency Suicide Prevention Group)은 자살로 추정되는 사망이 발생할 시 즉각적으로 중재(intervention)를 진행할 수 있으며, 자살 군집화(clustering)의 가능성을 확인할 수 있음(PHE, 2014). 

◯ 실제로 영국 정부는 효과적인 자살예방 계획 수립 및 시행을 위해 각 지역이 ONS 사망통계 및 검시자료를 포함한 자살과 관련된 여러 자료를 모두 활용하여 자체적으로 자살 데이터를 수집하고 적시에 대응할 것을 강조함. 따라서 영국 정부는 일반의 진료, 일차 진료, 정신과 진료, 응급실 진료, 경찰 자료, 사회복지, 교도소 및 보호관찰, 주거, 교육, 철도 등의 자료를 수집하는 여러 기관으로부터의 원활한 지역자료 공유를 권장함. 

◯ 구체적인 실시간 감시체계 도입의 목적은 다음과 같음(PHE, 2014):

 자살 발생 시 신속하게 유가족 및 해당 커뮤니티에 지원 제공 

 자살 확산을 방지하기 위한 특정 학교 혹은 감옥 등의 고위험(at risk) 환경에서의 근무

 자살 hot spot 발견

 초기에 식별될 수 있는 새로운 방법 수립

◯ 실시간 감시체계의 예시로는 Durham County Council의 경찰 주도 자살 감시 시스템과 Cornwall and Isles of Scilly의 자살 관리체계가 있음. 

◯ 우선 Durham County Council의 경찰 주도 감시 시스템 하에서는 자살 사망 발생 시 경찰은 사망신고서에 관련 사항을 기록하고 이 자료를 검시관 및 관련 CCG에게 전송함. 이후 사망기록은 NHS 담당기관에 전송되며, 기록 검토 시 자살 군집화의 발생 가능성이 있는 것으로 판단될 경우 해당 지역의 대응 계획 및 지침이 시행됨. 이와 동시에 유가족 및 커뮤니티에게 If U Care Share Foundation(IUCSF) 기관을 통해 일대일 상담, 대인관계 및 재정적 지원, 커뮤니티 중재 등이 제공됨(PHE, 2016b).

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◯ 다음으로 2007년부터 체계적으로 도입된 Cornwall and the Isles of Scilly의 실시간 감시체계 하에서는 경찰관, 검시관, 일반의 및 지역 NHS trust(Cornwall Foundation Trust, CFT) 담당자가 자살로 의심되는 사망 건수를 모두 지역 PH에 전송함으로서 실시간 모니터링이 진행됨. 제공되는 모든 통계 및 요약 자료는 지역 자살 감시 그룹(Suicide Surveillance Group, SSG)에 보고됨. SSG의 분석을 바탕으로 PH는 기술통계 및 연간 감사결과를 작성하고 이는 자살예방 계획에 반영됨. 또한 이 과정에서 SSG는 자살 군집화 및 확산의 가능성을 MSPG에 별도로 보고하며 MSPG와 함께 관련 위험 가능성 및 방지 계획 등을 수립함. 기술통계 및 연간 감사결과는 이후 지역의 법정 단체인 Health & Wellbeing Board(H&WB)에 전송되어 최종적으로 보고됨(PHE, 2014), <그림 6>. 현재 Cornwall and the Isles of Scilly는 실시간 감시체계를 활용하는 보다 구체적인 대응전략을 수립하기 위해 PHE와 협력하고 있음. 

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◯ 자살 군집화와 관련해서는, 영국의 모든 지역은 PHE 주도 하의 multi- agency suicide prevention group(MSPG)를 설치하고 있음. MSPG는 전반적인 자살예방 계획을 수립하고 자살 군집화 대응 방안을 마련함. 따라서 자살 군집화에 대응하기 위해 모든 지역은 community action plan(CAP)을 개발하며, 이는 자살 및 자해 동향을 모니터링 하는 자살 감시 그룹(suicide surveillance group, SSG)과 계획을 시행하는 자살 대응 그룹(suicide response team, SRT)이 주도함(PHE, 2015). 

다. 지역 자살예방대책에서의 자살통계 활용

◯ 2012년 발표된 영국의 국가자살예방정책(Preventing suicide in England: A cross- government outcomes strategy to save lives)은 일반 인구의 자살률을 감소시키고 유가족을 지원하기 위해 다음과 같은 6개의 목표를 제시함(HM Government, 2012):

 자살 고위험군으로 분석된 청년 및 중년 남성, 정신건강 서비스 이용자, 자해 과거력이 있는 자, 형사법 체제(criminal justice system) 접촉자, 특정 직종 종사자 등의 자살 위험률 감소

 특정 그룹(아동 및 청소년, 성소수자, 사회경제적 약자 등)의 정신 건강 향상을 위한 맞춤형 접근 방식

 자살 수단에 대한 접근성 감소

 유가족 또는 피해자 지원

 부적절한 자살 보도 방지를 위한 미디어와의 협력

 연구, 데이터 수집 및 모니터링 지원

◯ 특히 영국의 국가자살예방정책은 지역별 대응을 강조하고 있으며, 모든 지역은 영국의 Department of Health, PHE 및 NHS의 지원을 바탕으로 여러 관련 기관간의 협력을 요하는 multi- agency suicide prevention and action plan을 제시함. 따라서 각 지역은 지역별 맞춤 자살 대응 방안을 마련하고 이를 국가 차원에서 지원함<그림 7>, (HM Government, 2012).

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◯ 이후 각 지역은 국가 자살 데이터 및 지역 정보를 분석하여 해당 지역의 고위험군 및 자살 추세를 파악한 후 이를 바탕으로 근거 기반의 대상 중재를 제공하고 이의 결과 모니터링과 평가를 진행함(PHEa, 2016). 

◯ 자료 수집 및 통계 분석 책임은 각 지역의 PH에 있으며, 지역 자살예방대책 시행에 있어서 ONS의 사망통계와 PHE의 Suicide Prevention Profile가 기본적으로 활용되고 필요할 경우 이에 추가적으로 지역 데이터가 사용됨. 특히 Suicide Prevention Profile을 통해 영국 평균 대비 각 지역의 자살 관련 지표 현황을 파악할 수 있음<그림 8>, (PHEa, 2016). 

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◯ 또한 자살의 맥락과 추세를 정확히 이해하는데 있어서 여러 지역 기관들의 데이터를 이용하는 것이 효과적인 것을 감안하여 영국 정부는 기관간의 데이터 공유를 강조함. 예를 들어 The London Borough of Bromley는 여러 자살 관련 데이터를 기반으로 자살 예방 데이터베이스(suicide prevention database)를 구축하였는데, 여기에 활용되는 자료로는 일차의료 사망 데이터(Primary Care Mortality Database), 일반의 자료(General Practice Medical notes), 입원 진료 자료, 정신과 기록, 검시 자료 등이 있음(PHEa, 2016). 따라서 영국은 주기를 특정하지 않고 자살 관련 지역 자료와는 별개로 생산되며 특정 자살 수단의 급격한 상승 및 잠재적인 자살의 군집화 경향을 파악하기 위한 수단인 Rapid Intelligence Gathering 방법을 통해 신속하게 다양한 자살 관련 자료를 수집하고 있음. 

◯ 이외에도 실시간 감시체계가 운영되고 있는 지역에서는 모니터링을 통해 자살 추세 및 ‘hot spot’을 신속하게 파악하고 군집화의 가능성을 조사하여 실시간으로 대응하고 있음. 특히 감시체계 데이터는 자살 케이스를 신속하게 파악 가능하게 함으로서 각 지역 담당 기관이 미디어와의 협력을 통해 자살 보도 방향을 미리 설정하는 등, 적절한 대응 조치를 취하는데 활용이 가능함(Gale, 2017). 

4. 해외 자살 통계 시스템 비교 요약

◯ 국가 자살통계의 특징은 다음과 같이 요약될 수 있음; 1) 자살통계 책임기관은 일본은 후생노동성, 호주는 통계청, 그리고 영국은 통계청 및 지자체로 확인됨. 2) 자살통계의 생산 주

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기는 호주는 몇몇 예외적인 주를 제외하고는 국가 자살통계를 연간으로 발표하고 있고, 일본과 영국은 연간 통계와 더불어 단기 통계를 동시에 생산하고 있음. 3) 통계 작성 경로를 살펴보면 일본은 경찰청과 후생노동성의 통계를 기반으로 자살통계가 생산되고 있음. 이에 반해 호주에서는 검시 자료가 주되게 사용되고 있으며, 영국은 경찰, 감옥, 이민청, 검시관 등으로부터의 다양한 자료를 활용하고 있음. 4) 자살예방에서 다부문 접근의 시도는 특히 일본에서 두드러지며 우선순위 패키지를 활용하여 자살의 복합적 원인에 대해 접근하고 있음 <표 3>.

◯ 자살 통계 구축과 관련하여 세계적으로 확인되는 추세는; 1) 자살통계 집계의 속도를 높이는 것은 공통된 방향이며, 국가마다 그 단계는 달라 일본은 도도부현/시정촌까지 월별 자살 통계를 생산하고, 호주에서는 Queensland, Victoria 지역에서 우선적으로 실시되고 있으며, 영국에서는 시범사업을 통해 real time surveillance를 모색하는 단계에 있음. 2) 자살동향 감시를 위한 단기 자살통계의 생산을 적극적으로 모색하고 있음. 이를 담당하는 책임기관은 국가마다 차이를 보여, 일본은 중앙의 JSSC에서 직접 생산하여 지방정부에 제공하며, 영국은 지역정부(borough)의 공중 보건팀에서 그 생산을 담당하고 있음. 3) 자살 통계를 지역단위 자살예방 계획 수립에 적극적으로 활용하려는 목적이 강화되고 있음. 즉, 기초 지자체 단위의 지역을 매개로 자살통계와 자살예방 계획 간의 연계성을 높이고 있음<표 3>.

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표 . 국가별 자살통계 관련 주요내용

국가			일본	호주	영국
통 계 생 산	공 식 통 계 *	작성기관 (영문/한글)	MHLW(일본 후생노동성)	ABS(호주통계청)	ONS(영국 국가통계청)
		작성체계	지자체별 인구동태통계를 바탕으로 수집	각 주 및 지역에 배치된 검사관이 입력한 사망 정보를 바탕으로 작성	의사 및 검시관이 작성하는 사망신고서를 바탕으로 기록
		항목	성별, 연령, 동기/원인, 자살 시점(월), 지역, 자살 장소, 직업, 거주형태	성별, 연령, 인종, 경제활동 상태, 혼인 상태, 사망 원인, 사망 지역, 자살 방법, 담당 조사 지역	성별, 연령, 지역, 사망 원인, 자살 방법
		공표주기	1년	1년	1년
	실 시 간 감 시 체 계	작성기관 (영문/한글)	MHLW(일본 후생노동성)	QSR/iQSR: Australian Institute for Suicide Research and Prevention(AISRAP) VSR: Coroners Court of Victoria	ONS, local authority
		작성체계	지자체별 인구동태통계를 바탕으로 수집	QSR: 경찰 보고(Form 1 Police report) 바탕 검시 자료, 검시관 보고, 부검자료 및 독극물 보고(toxicology report)를 바탕으로 구축 VSR: 검시관 보고를 바탕으로 수집	경찰, 감옥, 이민청, 검시관 등 여러 경로로부터의 자료를 바탕으로 작성
		항목	성별, 연령, 동기/원인, 자살 시점(월), 지역, 자살 장소, 직업, 거주형태	QSR: 성별, 연령, 지역, 소수자 여부, 자살 원인 및 방법, 결혼 및 취업상태, 정실질환 관련 자료, 신체 질환 여부 등 VSR: 성별, 연령, 자상 방법 및 장소, 원주민 여부, 성소수자 여부, 타문화 및 타 언어 사용자 여부, 직업 상태, 결혼 상태	자살 수단 및 장소, 시간, 상세   개인정보, 지역 상황, 직업 상태, 소수자 여부
		공표주기	1달(Prompt Vital Statistics Report)	QSR: 4개월, VSR: 1년	비정기적(Rapid intelligence gathering), 1년
정 책 활 용		활용기관 (정책총괄기관)	JSSC (자살대책추진본부)	중앙 정부 주 및 지역 정부	중앙 정부 지역 정부
		활용자료	후생노동성 자살통계와 경찰청 자료	ABS 사망원인자료, Queensland Suicide Register(QSR), Victoria Suicide Register(VSR)	ONS 사망통계, Public Health England Suicide Prevention Profile,  local authority 자료,  실시간 감시체계 자료
		활용방법	actual local suicide conditions profile, local suicide countermeasure policy package	National Suicide Prevention Strategy, 주 및 지역별 맞춤 자살예방대책	지역별 multi- agency suicide prevention and action plan

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제 3절 국가자살동향감시 시스템 활용도 제고 방안 및 자살통계 보완 사항

1. 도입 예정인 국가자살동향감시 시스템

◯ 현재 도입 예정인 통계청의 국가자살동향감시 시스템(National Surveillance System on Suicide Trend)은 자살의 추이를 모니터링 하여 자살예방 정책의 효과성 및 시의성을 제고하고, 자살률 동향을 예측할 수 있는 관련통계를 신속하게 활용하고자 함<그림 9>. 국가자살동향감시 시스템은 크게 통계청 사망신고자료와 경찰청 수사기록을 연계하여 자살 잠정 동향을 파악할 예정이며, 이외에도 국립의료원의 자살시도자 정보, 교육부의 학생자살 보고자료 등을 추가 비교분석하여 자살동향 파악에 활용할 예정임. 해당 자료의 접근 및 확인은 국무조정실, 보건복지부, 지자체 등을 포함한 자살예방 관련 기관으로 한정될 예정임. 국가자살동향감시 시스템 도입으로 인해 신유형의 자살자 마이크로데이터 확보 및 활용이 가능할 것으로 기대됨.

◯ 국가자살동향감시 시스템은 경찰청 수사기록과 통계청 시체검안서를 연계하여 사용할 예정인데, 이는 일본이 경찰청 수사기록만 활용하는 것에 비추어 볼 때  진일보한 것으로 판단됨. 국가자살동향감시 시스템의 활용은 자살예방에 대한 지역 내의 지속적인 관심을 유지하고 집중할 지점들을 발견하는데 있어서 중요할 것이며 이의 활용도를 제고하기 위해서 아래에 나열된 사항에 대한 고려가 필요함.

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2. 국가자살동향감시 체계 활용도 제고 방안

가. 자살동향 감시 체계 수집 지표에 대한 검토

◯ 자살동향 감시체계에서 수집되는 통계지표는 성별, 연령, 교육정도, 직업, 장소, 수단, 원인 및 동기 외에 가족관계(동거인 여부), 일시 등의 정보를 포함함. 이에 더해 장소, 특히 소규모 지역(예: 읍면동)별 통계를 추가적으로 포함하는 것에 대한 고려가 필요함. 자살에 대한 즉각적인 대응을 위해서는 자살 장소를 자택, 공공장소, 숙박업소 등으로만 구분하는 것으로는 부족함. 이와 관련해서는 영국의 실시간 자살 감시체계는 핫스팟, 군집[지역, 자살 수단, 연령, 직장에 대한 확인을 그 운영의 목적으로 삼고 있다는 점을 주목할 필요가 있음. 물론 자살이 드문 사건이며 읍면동의 소규모 지역 단위는 개인을 특정할 우려가 있다는 점을 고려해야하고, 해당 지자체가 관내의 경찰서 등 내부적 확인 과정을 통해 가늠할 수도 있을 것임. 읍면동 단위의 주소지 정보가 제공되지 않을 경우, 자살증가율이 시군구 단위에서 크다면 자살 핫스팟이나 군집(cluster)을 발견하고, 즉각적인 계획 수립을 위해 시간과 장소에 대한 상세한 추가분석을 제공할 필요가 있음. 

◯ 자살동향 감시체계의 활용도를 높이기 위해 인구 사회학적 정보, 자살원인, 자살 수단에 기반한 일정한 시기별 지역간 비교에 대한 정보를 제공해야 함. 의미 있는 비교를 통해서 현재의 추이와 상태를 인지하도록 지역 예방활동을 추동하고, 예방활동의 영역을 설정할 수 있도록 해야 함. 

◯ 경찰 변사자료에서는 추정되는 자살원인을 유가족의 진술을 토대로 파악하고 있음. 현행 자료에서는 단 하나의 자살원인만을 파악하고 있어 가살이 다양한 원인을 갖는 다는 점에 비추어 과소추정이나 오분류(misclassification)의 가능성이 높음. 따라서 뒤에서 다시 다루겠지만 자살이 복합적 원인의 결과라는 점을 고려하여 자살원인을 3개까지 추정하는 것이 바람직할 것임. 

나. 자살동향 감시체계의 생산과정에 대한 검토 

◯ 자살통계의 생산은 일본은 후생노동성의 JSSC, 영국은 지역 정부가 담당하고 있는 반면 우리나라는 통계청이 담당하고 있음. 자살통계를 자살예방과 밀접하게 연관 짓기 위해서는 통계의 생산에서 그치지 않고 데이터의 해석이나 추가 분석 등에 대한 능동적인 계획이 필요함. 우리나라의 경우 일본과 마찬가지로 통계 생산과 활용하는 기관이 분리되어 있으며, 이는 기초 지자체의 역량을 고려할 때 불가피한 측면이 있음. 이로 인해 지역 단위 자살위기 상황에 대한 신속한 개입이 지체될 여지가 있으며, 대책이 고려되어야 함. 예를 들어, 동향감시체계에서 한 시군구의 월별 자살 추이가 증가하는 경우 광역 혹은 중앙의 정책적 지원이 필요하며, 일본이 기본 패키지와 우선 패키지 등의 사전 개발 후 지역특성에 맞는 정책 조합을 이용하도록 하는 방안, 도도부현에 정책 지원역량 확보하는 방안 등은 의미 

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있는 방안이 될 수 있음. 

◯ 단기 및 지역 데이터의 신뢰도 제고를 위하여 향후 자살동향 감시체계는 집계 이후 그 예측의 정확성에 대한 검토가 반드시 요구됨. 이를 위해 1)단기 통계(1차 취합) 에 포함되는 자살 건수의 양, 2)자살동향 감시체계(자동원사인)와 이후 보완된 최종 사망원인 간의 일치도 및 주요 변수들(성별, 수단 등)의 일치도에 대한 오류 분율의 검토가 필요할 것으로 판단됨. 

3. 국가 자살통계 보완 사항

가. 학생 자살통계 확보체계 마련

◯ 우리나라의 2016년 10세에서 19세 연령층의 사망 원인 1위는 고의적 자해(자살)로, 이에 대한 효과적인 대응계획 시행의 중요성이 부각됨(보건복지부, 중앙자살예방센터, 2018).

◯ 현재 학생 자살현황은 학교 및 교육청 보고를 통해 확인하고 있어, 실질적으로 학생 자살현황 파악을 위해 확보 가능한 자료는 모두 보고기반 자료이며 이는 통계로서의 한계점을 보임. 현재 학생 자살 보고체계는 지역별 편차가 있고 기록 누락의 가능성이 존재함. 실제로 교육부와 통계청의 학생 자살관련 통계 수치가 서로 불일치하는 경향을 보이고 있으며, 정확한 학생 자살 건수 파악이 어려운 실정임.

◯ 이에 대한 개선방안으로 경찰청의 자살 관련 자료와 교육부의 보고기반 자료를 연계하여 학생 자살통계 확보체계를 마련하고, 도입 예정인 국가자살동향감시 시스템 내에 학생 자살통계 DB를 구축할 필요가 있음. 

◯ 이외에도 청소년건강행태온라인조사, 한국아동·청소년 인권실태조사와 같은 자료는 학생들의 자살 생각, 자살 계획, 자살 시도 등을 조사하고 있어 이를 자살 사망의 대리변수로 활용하여 대략적인 학생 자살현황 파악이 가능할 것으로 예상됨.

나. 경찰청 변사자료 기록 보완: 자살 수단 및 원인 분류의 세분화

◯ 현재 경찰청에서는 범죄정보관리시스템을 통해 자살을 포함한 범죄통계 기록을 관리하고 있으며, 경찰청 변사자료에 포함되는 항목은 성, 생년월일, 성별, 발견 장소, 발견일시, 사망추정일시, 사망구분, 사망수단, 자살형태, 타살형태 및 사건개요임. 실제로 경찰청 범죄수사규칙은 검시조서를 통해 변사자에 대한 인적사항과 변사 장소 및 일시, 사인, 발견자, 관련자 진술, 의견 등을 기록한다고 명시함. 이를 바탕으로 파악 가능한 자살자의 정보는 <표 4>에 제시됨. 

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표 . 현재 자살추정사건 자료 항목

항목
지역	장소 및 주소지 정보
연령대	10세 미만, 20세 이하, 21- 30세, 31- 40세, 41- 50세, 51- 60세, 61세 이상, 미상
자살원인	가정문제, 경제생활문제, 육체적 질병 문제, 정신적/정신과적 문제, 직장 또는 업무상의 문제, 기타, 미상
성별	남, 여, 미상
직업	농/임/수산업, 자영업, 전문직, 공무원, 일반봉급자, 유흥업종사자, 일용노동자, 기타 피고용자, 무직자, 기타
학력	초등학교, 중학교, 대학교, 4년제 대학, 대학원	재학 중, 졸업, 중퇴
자살수단	목맴, 가스중독사, 익사, 추락, 교사, 도검, 총포, 폭발물, 음독, 기차, 자동차, 비행기, 소사, 전기, 기타

◯ 현재 경찰청 변사 자료의 많은 정보는 텍스트 형식으로 구성되어 있는데, 사망 수단 및 원인이 세분화된 표준화된 양식을 구축하여 활용 시 구체적인 자살 관련 내용이 파악 가능할 것으로 예상됨. 특히 경찰청 변사 자료의 경우 기재된 정보의 재확인 및 수정·보완이 어려운 제한점이 있는 것을 고려하였을 때, 보다 신속한 자살 관리 및 체계적인 통계 생산을 위해 자살 발생 현장에서 조사 담당 경찰관이 활용하는 변사자 체크리스트를 보완하여 자살 관련 내용을 파악할 필요가 있음. 

◯ 이와 관련해서는 우선 자살수단 세분화에 대한 고려가 필요한데, 특히 가스중독사에 대한 추가 분류가 요구됨. 현재 사망원인통계는 한국표준질병사인분류(Korea Informative Classification of Diseases, KCD)를 기준으로 사망원인을 기재하고 있으며, 중앙자살예방센터는 KCD 코드를 중심으로 자살 수단을 아래와 같이 분류함<표 5>.

표 . 자살 수단 분류(중앙자살예방센터, 2018)

대분류	코드	내용
약물음독	X60	비마약성 진통제, 해열제 및 항류마티스제에 의한 자의적 중독 및 노출
	X61	달리 분류되지 않은 항경련제, 진정제- 최면제, 항파킨슨제 및 향정신성 약물에 의한 자의적 중독 및 노출
	X62	달리 분류되지 않은 마약 및 환각제에 의한 자의적 중독 및 노출
	X63	자율신경계에 작용하는 기타 약물에 의한 자의적 중독 및 노출
	X64	기타 및 상세불명의 약물, 약제, 생물학적 물질에 의한 자의적 중독 및 노출
	X65	알코올에 의한 자의적 중독 및 노출
	X66	유기용제 및 할로겐화 탄화수소 및 그 휘발물질에 의한 자의적 중독 및 노출
가스중독	X67	기타 가스 및 휘발성 물질에 의한 자의적 중독 및 노출
농약음독	X68	살충제에 의한 자의적 중독 및 노출
기타 화학물질	X69	기타 및 상세불명의 화학물, 독성물질에 의한 자의적 중독 및 노출
목맴	X70	목맴, 압박 및 질식에 의한 의도적 자해
익사	X71	물에 빠짐에 의한 의도적 자해
총화기	X72	권총발사에 의한 의도적 자해
	X73	라이플, 엽총 및 기타 소화기 발사에 의한 의도적 자해
	X74	기타 및 상세불명의 화기 발사에 의한 의도적 자해
	X75	폭발물에 의한 의도적 자해
분신	X76	연기, 불 및 불꽃에 의한 의도적 자해
	X77	증기, 뜨거운 김 및 뜨거운 물체에 의한 의도적 자해
둔기/예기	X78	예리한 물체에 의한 의도적 자해
	X79	둔한 물체에 의한 의도적 자해
추락	X80	높은 곳에서 뛰어내림에 의한 의도적 자해
자동차/기차	X81	움직이는 물체 앞에 눕거나 뛰어내림에 의한 의도적 자해
	X82	자동차의 충돌에 의한 의도적 자해
기타	X83	기타 명시된 수단에 의한 의도적 자해
	X84	상세불명의 수단에 의한 의도적 자

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◯ 2016년 수단별 자살 현황을 살펴보면, 남성은 목맴, 가스중독, 추락 순으로 자살률이 높았으며, 여성은 목맴, 추락, 가스중독 순으로 자살률이 높음(중앙자살예방센터, 2018). 따라서 가스중독은 주요 자살 수단 중 하나로 지목되고 있어 이에 대한 자살예방 정책 수립이 중요할 것으로 파악됨. 

◯ 가스중독으로 인한 자살의 경우, 번개탄, 갈탄, 연탄 등 여러 요인이 사망 요인으로 작용할 수 있어 각 항목에 대한 구체적인 정책 시행이 필요하고, 이를 위해서 가스중독에 사용된 매체를 성형목탄, 연탄, 갈탄, 산화질소, 플루오린가스, 부탄가스 등으로 구분하여 기록할 필요가 있음. 이와 관련하여 산림청은 보다 정확한 번개탄 관련 자살예방 정책 추진을 위해 가스중독 자살 데이터의 필요성을 강조하고 있음. 하지만 현재 가스중독 수단별 통계자료가 없고, 특히 번개탄을 구분할 수 있는 코드를 별도로 찾기 어려워 가스중독에 의한 자살이 모두 번개탄으로 이루어진다는 오해가 흔함. 실제로 산림청은 이로 인해 번개탄 생산 업체로부터의 민원인 발생하고 있으며, 정확한 데이터 부족으로 인한 번개탄 관련 정책 추진에 어려움을 겪는다고 보고함. 따라서 가스중독 사유를 변수로 추가하여 수단별 가스중독을 분별할 수 있는 자살통계를 생산하고 활용할 경우 활용 가치가 있을 것으로 확인됨. 이를 위해서는 현재 사망원인통계의 자살수단 코드는 WHO ICD- 10과 KCD- 7의 체계에 따라 분류되고 있어 변경이 불가하므로 경찰청 변사기록의 사망 수단 세분화가 요구됨. 

◯ 또한 자살 사망원인 기록 구분에 대한 검토가 필요함. 현재 경찰청은 크게 대구분 및 중구분으로 변사자의 사망원인을 기록하는데, 대구분에서는 사망 원인을 자살, 타살, 자기과실, 타인과실, 산업재해사 등의 항목으로 구분하고 중구분에서는 자살 사망의 경우 추정 원인을 가정문제, 남녀문제, 사별문제, 육체적 질병 문제, 정신적·정신과적 문제, 경제생활문제, 직장 또는 업무상의 문제, 학대 또는 폭력 문제, 기타 혹은 미상으로 기록함. 이와 관련

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하여 현재 자살추정사건 통계 수집 시 사용되는 원인 항목은 <표 6>에 제시됨. 하지만 일반적으로 자살은 여러 요인이 복합된 결과인 것을 감안할 때, 자살 사건 기록 시 3개의 자살 추정 원인을 표시하고 이 중 가장 핵심적인 요인을 별도로 선택하도록 하는 수정 방안에 대한 고려가 필요함. 실제로 일본의 경우 자살 사건 조사 시 원인을 3개 항목까지 표시하고 있음.

표 . 자살사망사건 통계 수집에 사용되는 사망구분표

사망구분표
사망大구분	사망中구분	사망구분
자살원인	가정문제	배우자와의 갈등
		부모와의 갈등
		자녀와의 갈등
		기타가족과의 갈등
	남녀문제	교제와 관련된 갈등
		실연
		결혼과 관련된 갈등
		기타
	사별문제	기타, 연인, 친구의 사망
		기타, 연인, 친구의 자살
	육체적 질병 문제	HIV/AIDS
		원치 않는 임신
		육체적 질병
		기타
	정신적, 정신과적 문제	알코올중독 및 약물의존
		산후우울증
		기타우울증
		기타
	경제생활문제	빈곤
		부채
		기타
	직장 또는 업무상의 문제	직장 내 또는 업무상 갈등
		사업실패
		실직
		미취업
		기타
	학대 또는 폭력 문제	성적 학대
		육체적 학대
		방치
		기타
	기타	종교문제
		문화문제
		학교문제
		법률적 상황
		친구문제
	미상	미상
자살수단의 종류	목맴, 가스중독사, 익사, 추락, 교사, 도검, 총포, 폭발물, 음독, 기차, 자동차, 비행기, 소사, 전기, 기타

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◯ 따라서 현재 사용되는 경찰청 변사자 체크리스트를 보완하여 자살 의심 사건 발생 시 구체적인 자살 관련 내용이 파악 가능하도록 나아가야 하며, 이러한 맥락에서 경찰청 변사자 체크리스트에 추가하여 활용할 수 있는 표준서식 항목을 제시함<표 7>. 이 연구는 구체적인 자살 원인 및 수단 관련 체크리스트를 현재 사용되고 있는 변사자 체크리스트 양식에 추가할 필요를 반영하여 <표 7>을 제시하였음. 자살 수단 및 원인 이외의 기타 수집 항목은 현재 사용 중인 변사자 체크리스트와 동일하게 작성하면 될 것으로 판단됨. 

◯ 마지막으로 <표 7>과 같이 체크리스트 양식을 보완하고, 수집되는 자료를 바탕으로 보다 세부적인 통계 작성이 가능할 경우 자살위험요인 파악 및 예방정책 수립에 많은 도움이 될 것으로 예상됨. 구체적으로 통계의 시간적 연계성을 위해 주 자살통계는 현행과 동일하게 작성하되, 부 자살통계는 보다 세세하게 분류된 자살 수단(가스중독 자살 사용매체) 및 원인(사망 하위 구분)을 반영하여 추가적으로 작성하는 방안을 건의함. 특히 부 자살통계에는 최대 3개까지의 자살 원인을 모두 반영하여 보다 종합적인 자살 원인 파악이 가능하도록 할 필요가 있음. 

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제 3장 자살 연관 통계

제 1절 자살 선행지표의 도출

1. 자살예방의 다층적 접근을 위한 연관통계의 필요성과 연구 내용

◯ 자살은 취약성과 위험요인 보호요인의 작용의 결과로 볼 수 있음. 성소수자, 자살 시도자, 유가족과 같은 인구집단은 취약성을 갖게 되며, 이들은 위험요인의 노출되는 정도도 높음. 자살의 대표적인 위험요인으로는 자살 시도 경험, 정신질환, 일반질환 및 통증, 부적절한 알코올 사용, 실직 및 경제적 손실, 절망감, 가족력, 유전적 요인, 차별, 갈등, 사회적 고립 등이 있음(WHO, 2014). 자살예방 정책은 위의 일부 요인에 대한 제한적 접근으로는 단기적 성과를 얻는데 그치기 쉬우며, 취약성과 사회적 위험 요인에 대한 개입을 동반할 때 자살예방 성과는 근본적인 변화를 이끌어 낼 수 있음. 

◯ 기존 국내 자살 연구와 정책은 자살의 일부 위험요인의 독립적 영향에 집중하는 경향을 보임. 대상의 측면에서의 고위험 요인(우울증 등)이 주를 이루었으며, 시기적 측면으로는 자살 직전의 상황[자살 수단, 위기 개입(hotline)]에 집중하여 왔음. 하지만 자살은 장기적으로 누적된 위기 과정의 중첩으로 이해할 필요가 있고, 다방면의 자살 위험 요인에 대한 연구가 필요함. 따라서 보다 폭넓은 자살 위험요인 연구 진행을 위해 국내외 자살 관련 연구를 통한 국내 연구의 한계점 확인 및 이를 보완하기 위한 자살 연관통계의 활용 가능성을 파악할 필요가 있음. 

◯ 본 장에서는 자살과 관련성이 깊으나 자살에 대해 간접적이거나 그동안 자살 예방 대책에서 주되었던 보건의료적인 개입이 아니라는 이유로 간과되어왔던 영역을 연관통계로서 부각하고자 하여, 이들 영역에서 주요한 자살 선행지표를 도출하고자 함. 구체적으로는 1) 자살 위험요인에 대한 문헌고찰을 통해 연관통계 영역을 도출할 것이며, 2) 국내 자살 예방 연구의 관점이 제한적임을 한국 스웨덴, 일본에서 시행된 자살 연구의 대상과 주제 등을 비교하여 보이고자 하며, 3) 보건복지, 노동, 사회의 몇몇 중요한 연관통계 영역에 대해서는 해외사례 검토를 통해 연구와 정책 실현의 가능성을 제시하였으며, 4) 현시점에서 연관통계를 활용하기 위한 방법으로서 데이터 링키지를 제시하고 분석을 통해 그 실제적인 적용 사례를 보여 줌. 

2. 자살 위험요인에 대한 문헌 고찰

◯ 자살 선행요인에 대한 포괄적 위험요인에 대한 연구는 소수에 그침. 일본 자살예방 센터에서는 “시정촌 자살 대책계획 수립 지침서”를 통해 “자살대책은 보건, 의료, 복지, 교육, 노동 및 그 외의 관련 시책과 유기적으로 연계되어 삶은 위한 포괄적 지원”으로 실시되어야 함을 강조하고 있음. 위의 지침서에서는 포괄적 지원을 위해 정신보건적인 관점뿐만 아

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니라 사회 경제적인 관점을 포함하는 것이 중요하며, 실업, 다중채무, 생활고, 빈곤, 아동학대, 성폭력 피해, 은둔형 외톨이, 성적 소수자 등 취약성을 강화시키는 영역에서 연계를 강조하고 있음<그림 10>, (JSSC, 2018).  아래 그림은 일본 자살예방 센터가 자살에 이르는 경로와 위험요인을 어떻게 바라보는지, 그 연장에서 자살예방 대책을 어떻게 추진하는지 잘 보여주고 있음. 

◯ 스코틀랜드 정부의 “Risk and protective factors for suicide and suicidal behaviour: a literature review”보고서는 자살 위험요인에 대한 가장 체계적인 문헌고찰로 판단됨(Scottish Government Social Research, 2008). 이 보고서는 자살연구들에 대한 광범위한 문헌을 대상으로 체계적 고찰을 통해 개인별 위험요인, 사회 심리적 위험요인, 개인별 보호요인, 사회 심리적 보호요인을 제시하고 있음. 보고서는 개별요인 각각에 관한 연구에서 나타난 결과들을 토대로 종합적인 결론을 제시하고 있음. 예를 들어, 보호요인으로서 제시되는 결혼과 파트너십은 5개의 연구를 근거로 결혼과 파트너십이 이성애자 사이에서 뿐 아니라 동성애자 간에도 보호효과가 있으며, 이 효과는 여성 보다는 남성에서, 흑인 여성 보다는 백인 여성에서 효과가 더 크다고 밝히고 있음. 이 보고서는 개별 요인 하나하나의 결과를 소개하지는 않으며 아래 그림은 스코틀랜드 정부 보고서를 통해 밝혀진 자살 관련 요인들에 대한 요약임<그림 11, 12>. 

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◯ 위의 스코틀랜드 보고서는 위험요인 각각에 대한 근거 고찰과 확인을 통해 스코틀랜드 사회에 적용 가능한 요인과 취약집단(groups at risk of suicide)에 대한 이해가 중요함을 강조함. 보고서는 위험요인과 보호요인에 대한 정리를 통해 자살 예방 대책의 정책이 보완되어야 하는 방향에 대해 아래와 같이 제시하고 있음. 

 사회적 불평등으로 인해 초래되는 사회적 구조적 위험요인에 대한 중재

 일반인구 집단에서의 개인적, 사회 심리적 보호요인의 강화

 가족과 지역사회와의 연계성 증가

 자살률을 높일 수 있는 특정집단을 향한 사회적 제도적 불합리한 가치와 신념에 대한 도전

- 36 -

 개인 혹은 지역을 단위로 한 다양한 위험요인이 관여하는 자살 메커니즘의 발견

3. 자살 선행지표의 도출

◯ 일본과 스코틀랜드의 보고서 외에 특정 집단의 자살 위험요인을 고찰한 연구들을 더 살펴볼 수 있음. 예를 들어 자해 시도자들(Chan et al, 2016)이나 우울증 환자(Hawton et al, 2013)의 자살 예측요인에 대한 고찰 연구 혹은 정신질환자에서의 위험요인(Brown et al, 2000) 등이 그러한 연구들임. 이들 연구에서 언급되는 위험요인과 취약집단을 정리하면 정신질환, 신체질환, 수면 장애, 유전적 요인, 성격, 관계적 요인, 사회경제적 수준, 실직 및 직업 특성, 다중채무자, 범죄 경력 보유자, 가정폭력 피해자, 자살 시도자 및 유가족으로 등을 포함하는 것으로 확인됨<표 8>. 

표 . 자살의 위험요인 및 국내 데이터를 활용하여 자살과의 연관성 분석 가능여부

영역	세부영역	위험요인	분석 가능여부
			자살 생각	자살 사망
개인적 요인	인구학적 특성	성, 연령, 인종	O	O
		가구구성(한 부모 가정 포함)	O	X
		지역(지방, 대도시)	O	O
		종교	O	X
		기타(visible minority)	X	X
	Exposure to adversity	학대 경험	X	X
		가족의 자살력	X	X
보건복지	정신 관련 요인	정신질환(진단, 발병 시기, 기간, 중상정도 및 영향력, 병전 기능, 질환의 수)	O	O
		수면 장애(불면증, 잠의 충실도)	O	O
		자해(방법, 반복 시도)	X	O
		부모 또는 자식의 정신질환	X	X
		인지력	O	O*
	신체 관련 요인	신체질환(진단, 발병 시기, 기간, 중상정도 및 영향력, 병전 기능, 질환의 수)	O	O
		흡연(시작, 빈도, 종료) 및 음주(빈도, blood alcohol level)	O	O
		약물 사용(수면제 및 안정제 사용과 남용, 통증완화제 사용)	X	O
		비만(BMI)	O	O
		의도하지 않은 손상	O	O
		혈장, 콜레스테롤, 수축기 및 확장기 혈압, FEV, 협심증, MI, ECG abnormalities, 호흡기 증상, 숨 헐떡임, MRC, chronic bronchitis	O	O
		신체적 활동 정도	O	X
		장애	O	O
		Omega 3 fatty- acid factor	?	X
사회	사회경제적 요인	소득(개인 및 가구)	O	O
		건강보험	O	O
		연간 가구 지출	O	X
		사업실패(Demotion)	X	X
		교육 수준(본인 및 부모)	O	X
		자산	O	X
		부채	O	X
		다중채무	X	X
	사회적 관계망	고립감	O	X
		공격적 성향 및 충동	X	X
		사회적 지지의 결핍	O	X
		지역 사회 인물의 자살 목격 또는 경험	X	X
	주거	주거환경	O	X
노동	직업 관련 요인 및 직무 환경	취업상태(취업, 실업, 은퇴 등)	O	X
		스트레스(직무, 상실, 대인관계, 재정, 법적, 관계의 파괴, 트라우마)	O	X
	실업	실업 여부: 희망 및 가치의 상실, 좌절의 귀속, 부담	O	X

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*65세 이상 성인을 대상으로 분석 가능

- 38 -

제 2절 국가 간 자살연구 비교를 통한 한국 자살예방 연구의 제한성 검토

◯ 자살예방에 대한 연구와 정책의 폭과 관점은 자살연구의 주제들에 반영 된다고 할 수 있음. 제2절에서는 한국, 일본 및 스웨덴의 자살 관련 연구를 문헌 고찰하여 각 국가의 자살 연구영역을 비교분석 함으로서 한국 자살 연구의 제한성을 검토하고자 함. 

1. 자살예방 연구의 디자인적 측면 비교

◯ 자살관련 연구의 수는 2010년 이후부터 세 국가 모두 전반적으로 증가하는 추세를 보임<부록 표 2>. 총 연구 수는 한국이 가장 많았으나, 문헌의 결과변수를 ‘완료된 자살(completed suicide)’ 혹은 ‘자살 사망’으로 제한할 경우 한국이 가장 적은 수의 연구를 보유한 것으로 확인됨. 결과가 ‘완료된 자살’인 연구의 비율은 스웨덴(74.4%), 일본(55.3%), 우리나라(24.4%) 순으로 높음<표 9>. 

◯ 연구 디자인은 한국은 생태학적 연구(49.3%)를 가장 많이 시행하였으며, 패널/코호트 연구의 비율은 14.9%에 불과함. 이에 반해 스웨덴은 패널/ 코호트 연구(57.9%)의 비율이 높고 일본에서도 패널/코호트 연구(24.8%) 비율이 상대적으로 높음<표 10>. 

표 . 연구 디자인별 자살 관련 연구

연구 디자인	한국		일본		스웨덴
	N	%	N	%	N	%
Case report	2	3.0	8	7.6	0	0.0
Case- control	6	9.0	16	15.2	31	21.4
Cross- sectional	16	23.9	25	23.8	15	10.3
Ecological study	33	49.3	27	25.7	11	7.6
Panel/ cohort	10	14.9	26	24.8	84	57.9
Psychological autopsy	0	0.0	2	1.9	1	0.7
Qualitative	0	0.0	1	1.0	3	2.1
합계	67	100.0	105	100.0	145	100.0

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◯ 한국 자살예방 연구의 형식적 측면에 대한 검토는 방법론적 한계를 나름의 방식으로 극복하기 위한 시도들임. 종속변수에서 완료된 자살을 다룰 수 없을 때 자살 생각이나 시도라는 간접적인 지표를 대신하게 되며, 연구 디자인에서 다른 연구가 가능하지 않은 상황에서 근거수준이 제한적인 생태학적 연구에 과하게 치중되어 온 것임. 이는 활용 가능한 자살관련 데이터가 없는 상황에서 연구자들이 불가피하게 선택한 결과로 이해됨. 예를 들어 우리나라에서 사회경제적 상태와 자살에 관한 가장 기초적인 연구라 할 수 있는 실업과 자살의 연관성에 대한 연구를 살펴보고자 할 때, 경제활동 상태와 자살의 연관성, 실업기간과 자살의 연관성에 관한 데이터는 존재하지 않기 때문에 분석할 수 없으며, 연구자는 대신 실업과 자살의 연관성에 대한 환자 대조군 연구, 실업률과 자살률의 연관성에 대한 생태학적 연구, 혹은 실업기간과 자살 생각에 대한 코호트연구를 택하는 것이 최선임. 그러나 후자의 연구들은 어느 것 하나도 ‘한국에서 실업에 이르면 자살의 위험이 얼마나 높은지’, 또 ‘실업 기간이 오래면 그 위험은 얼마나 높아지는지’에 대해서 답을 제공하지는 못함. 이는 직업의 종류, 결혼, 부채, 사회적 관계망 등 거의 모든 다른 사회경제적 선행 지표에 대해서도 마찬가지임. 자살 원인에 대한 경찰청 조사는 이러한 데이터 빈곤을 메울 수 있는 편리한 자료원이 되어 왔으나, 그 한계는 매우 자명함. 

◯ 가장 중요한 사실에 대해서조차 정확한 통계 생산의 기반이 없는 것이며, 이는 자살 연관통계가 가지는 정책적 가능성과 가치에 대한 인식을 방해해 옴. 불과 2017년까지 건강보험데이터와 자살을 포함한 사망 데이터가 연계되기 이전까지만 해도 한국사회에서 심지어는 일반질환은 물론 정신질환의 자살에 대한 위험도 역시 제한된 인구집단(예:1개 병원)의 추계에 기대었던 것이 사실임. 자살 예방 정책이 근거에 기반을 두고자 한다면 자살 관련한 데이터의 이용 가능성을 제고하는 것이 우선적이라고 할 것임. 

2. 자살예방 연구의 내용적 측면 비교

◯ 결과변수가 ‘완료된 자살’인 논문을 대상으로 연구영역 비교를 진행한 결과, 우리나라에서는 자살방법, 인구학적 요인에 대한 연구가 가장 많이 시행됨. 사회경제적 요인과 취약성에 대한 연구 분류, 즉 Societal factors: Immigrants, unemployment, working conditions, occupation related, individual exposure to adversity(e.g. loss of parents, violence, homosexuality), etc.에서도 가장 낮음. 특히 실직에 관한 연구의 상당수가 생태학적 연구였다는 사실에 비추어 한국에서 사회경제적 혹은 취약 집단에 관한 연구는 매우 제한적이라고 할 수 있음. 또한 자살 중재(intervention) 및 지역사회(community and relationship factors)에 관해서는 일본의 연구가 많음<표 11>, [부록 1]. 

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◯ 또한 자살의 위험은 사회에 고르게 분포하기보다 그 사회의 특정 계기 속에서 어떤 인구집단에 집중된다고 할 때 자살 연구에서 취약집단에 대한 모니터링은 수시로 이루어져야 함. 예를 들어 이혼한 중년 남성, 동성애자, 주거 불안정한 남성, 등은 한국 사회에서 그 취약성이 집중되어 있다고 할 수 있음. 한국의 자살 연구는 정신질환, 일반 질환, 실업 등을 제외한 다른 하위 인구집단에 대한 연구가 드문 상황임. 이에 반해 스웨덴은 범죄자 및 출소자, 중독자 등을 포함한 다양한 취약집단 대상 연구를 발표하고 있음<표 12>.

- 41 -

◯ 문헌 고찰 결과 한국은 일본 및 스웨덴에 비해 가장 많은 수의 자살관련 연구를 게재한 것으로 확인됨. 하지만 연구의 결과변수를 ‘자살 생각’ 및 ‘자살 시도’를 제외한 ‘완료된 자살’혹은 ‘자살 사망’으로 제한할 경우, 한국은 가장 적은 수의 연구를 시행한 것으로 파악됨. 연구의 유형을 국가별로 살펴보면, 대부분의 국내 연구는 생태학적 연구 디자인을 활용함. 이와 달리 스웨덴의 많은 연구는 시간적 선후관계가 비교적 명확한 패널/코호트 디자인을 채택함. 연구 영역을 살펴보면, 한국은 자살 수단에 대한 연구가 많은 반면 사회경제적 영역과 취약 집단에 대한 연구는 비중이 적음. 특히 우리나라 연구의 상당수가 생태학적 연구인 것을 감안하면, 자살 위험요인에 대한 보다 심층적인 연구가 필요한 것으로 분석됨. 

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제 3절 자살예방의 다층적 접근의 중요성과 몇 가지 사례들

◯ 우리는 앞서 현재의 자살예방 정책이 충분히 포괄적이지 못하였으며, 그로 인해 자살예방은 구조적 요인에 대한 근본적 접근이 간과되었음을 지적하였음. 그 이유는 다양하게 이야기 될 수 있겠지만 우선 자살 문제는 보건복지부 자살예방정책과(2018년 이전에는 정신건강정책과)에 의해 주도되지만, 정책적 선택의 범위는 보건복지부 자체 혹은 통상적인 연계와 협력의 범위를 넘어섬. 포괄적 정책 전개를 가능하게 할 정치적 장치가 필요했으며 이러한 점에서 현재 국무총리 조정실이 더욱 적극적으로 부처들의 정책적 의지, 이를 뒷받침하기 거버넌스, 다양한 부처를 아우르는 정책적 비전을 제공하는 것이 필요함. 

◯ 제3절에서는 자살예방 정책의 확대 가능성을 모색하기 위해 정신질환 관련 원인 외의 다른 영역들에서 자살문제에 관여하는지 보건복지(일반질환, 알코올 중독), 사회경제 및 노동 분야의 몇몇 사례를 중심으로 고찰함. 자살과 다른 영역이 어떻게 접목되어 다층적 자살 예방 정책의 기반을 이루는지, 연구들은 어떻게 이를 뒷받침하기 위해 연관통계를 활용하는지 구체적인 사례들을 통해서 살펴보았음. 

1. 보건복지 분야

◯ 보건의료시스템 수준에서의 대표적인 자살 위험요인으로는 의료접근성 제한을 지목할 수 있으며, 개인 수준에서의 보건 관련 자살 위험요인으로는 정신 질환, 부적절한 알코올 및 기타 약물 사용, 일반질환 및 통증, 자살 시도 경험, 가족력 및 유전적 요인 등이 있음. 대부분의 자살에는 여러 가지 원인과 경로가 있는 것을 고려할 때, 개개인의 건강과 밀접한 관련이 있는 보건 분야의 여러 자살 위험요인에 대한 연구 진행이 필요한 것으로 판단됨. 따라서 이 연구는 자살의 대표적인 위험요인으로 알려졌으나 관련 연구가 상대적으로 부족한 일반질환과 알코올 중독에 대해 고찰 및 통계분석을 진행하여 자살연구의 확충 가능성과 연관통계의 활용방안을 제시함. 

가. 일반질환과 자살

(1) 해외 연구현황

◯ 자살은 주로 우울증, 조현병, 불안장애 등을 포함한 정신질환과 연관성이 크게 나타나지만, 신체질환과도 관련이 깊어 노인 자살의 약 60%는 신체질환과 연관성이 있는 것으로 제기됨(Cattel & Jolley, 1995). 실제로 자살자의 사망 이전 의료이용 행태를 살펴보면 정신질환에 비해 일반질환으로 진료를 받은 경우가 많아, 정신과 이외의 의료인들을 위한 자살예방 가이드 개발 등의 중요성이 제기되었음. 많은 해외 선행연구들은 뇌졸중, 다발성 경화증, 혈액성 악성종양, 전립선암, 복강질환, 위궤양, 갑상선 항진증, 루게릭병, 파킨슨병, 간질 등

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을 포함한 여러 일반질환이 자살의 위험을 높일 가능성이 있는 것으로 발표함.

◯ 구체적으로 Juurlink 외의 연구는 신체질환 중 신경계 질환(파킨슨병, 간질), 순환기계 질환(협심증, 울혈성 심장질환, 뇌혈관 질환), 골다공증 등의 질병이 자살의 위험을 높이는 것으로 보고하였으며(Juurlink et al, 2004), 이와 비슷하게 Webb 외의 연구 역시 골다공증이 자살과 연관성이 있는 것으로 결론지었으며 (Webb et al, 2012), 알코올 장애 질환으로 인한 위장관 장애 또한 자살 사망률의 상승과 연관성이 있는 것으로 보고됨(Roberts et al, 2018). 마지막으로 완화의료 환자를 대상으로 조사한 결과, 약 18.9%의 자살이 일반질환과 관련이 있는 것으로 분석되었음(Fegg et al, 2016).

(2) 해외 정책사례

◯ 다수의 해외 국가자살대응전략에는 자살예방을 위한 문지기(gatekeeper) 교육 및 활용이 포함되고 있음. 일반질환과 자살과의 관련성을 고려하였을 때, 정신과 이외의 의료인, 특히 일반의(general practitioner)의 역할은 매우 중요함. 이는 많은 자살자가 사망 전 의료인을 방문할 가능성이 높기 때문인데, 실제로 자살 여성의 약 25- 50%는 자살 시도 이전에 의료기관을 방문한 경험이 있는 것으로 보고되고 있음(Devries et al, 2014). 실제로 영국의 경우, 많은 수의 정신질환 환자가 일반의 진료를 받고 있으며, 비슷하게 호주에서도 일반의로부터 서비스를 받는 정신질환 환자의 수가 증가하는 추세를 보임<그림 13>. 따라서 여러 의료인에게 종합적인 자살 관련 문지기 교육을 제공할 경우, 1차 의료기관에서부터 자살 위험이 높은 대상자를 선별하고 적절한 중재방안을 제공할 능력이 향상될 수 있음. 

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◯ 문지기를 활용한 정책사례로는 스위스의 자살예방 정책이 있음. 스위스의 자살예방은 각 26개 주가 담당하고 있으며, 예방 전략으로 문지기 교육, 자살 수단 제한, 미디어 모니터링, 감시, 자살 시도자 관리, 세계 자살 예방의 날 홍보, 유가족 지원 및 전화상담 서비스 등을 진행하고 있음(WHO, 2014). 특히 스위스의 Zug 주(canton)는 자살예방전략 2010- 2015(Suicide Prevention Strategy 2010- 2015)를 개발 및 시행하여 성공적으로 자살 사망률을 감소시킨 것으로 평가됨. 위에 나열된 여러 예방 방안과 더불어 정신과 및 관련 서비스 제공 클리닉이 비정신과 의료인에게 지원을 제공함으로서 문지기 교육을 완료하고, 이를 통해 자살 고위험군을 조기 발견하여 적절한 중재를 진행함(Federal Office of Public Health Switzerland, 2018). 

◯ European Alliance Against Depression(EAAD)은 유럽연합 집행기관(European Commission)의 후원을 바탕으로 2004년 설립되었으며, 총 17개 국가의 참여 파트너에게 우울 및 자살

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예방 프로그램을 진행하고 있음. 각 국가의 참여 지역은 여러 대응 프로그램을 시행하는데, 이는 일반의 트레이닝, 교사, 리포터 및 경찰을 포함한 관련 종사자 트레이닝 그리고 환자 및 유가족 지원 등을 포함함(WHO, 2014). 특히 우울 및 자살예방 관련 교육을 일반의들에게 제공하여 일반의들이 자살 고위험 군을 조기에 선별하고 적절한 중재를 진행할 수 있도록 하고 있으며, 이와 동시에 고위험 군에 제공될 중재 프로그램 개발 및 조직화를 진행함(Hegerl et al, 2008). 

(3) 국내 연구 및 정책 동향

◯ 국내에서도 파킨슨병, 간질 등을 포함한 신경질환 및 암의 자살 영향에 대한 연구가 발표되었으나, 개별질환의 영향과 더불어 특정질환을 중심으로 여러 질환이 복합하는 양상을 반영하는 연구는 부족한 실정임. 또한 대다수의 연구 대상자가 1개 병원의 외래 및 입원환자로 한정된 제한점이 존재함. 

◯ 한국의료패널에서는 이환 및 의료이용에 대해 보다 자세히 측정하고 있어 일반질환과 관련된 연구 가능성을 제시하고 있음. 하지만 자살 사망이 아닌 자살 충동만을 측정하고 있는 제한점이 있음. 이를 보완하기 위해 자살 사망이 명시되는 국민건강보험공단 맞춤형자료 혹은 표본코호트 자료를 이 연구에서처럼 사용할 수 있으나, 그럴 경우 자료 한계점으로 인해 교육수준, 직종, 거주형태와 같은 자살과 관련성이 높은 변수에 대한 보정이 불가능함. 따라서 자살의 대표적인 위험요인과 자살사망여부를 동시에 측정한 데이터 구축 및 제공이 추후 필요할 것으로 판단됨.

◯ 현재 우리나라의 자살예방사업은 대부분 사회복지관, 노인복지관, 노인보호전문기관, 아동보호전문기관, 청소년상담지원센터, 정신보건센터, 국공립정신병원 및 기타 상담기관에서 담당하고 있음(한국자살예방협회, 2009). 또한 2018년 발표된 우리나라의 자살예방정책에 의하면, 자살예방 게이트키퍼 우선 양성 대상은 지역주민, 방문서비스종사자, 상담전문가 및 의료인력(정신의료기관 종사자)으로 명시됨(대한민국 정부 관계부처 합동, 2018). 하지만 대부분의 자살자가 사망 한 달 전에 1차 의료기관을 방문하는 경향을 반영하였을 때(Luoma et al, 2002), 국내에서도 정신과 외의 의료인 대상 자살예방 교육 도입을 고려할 필요가 있음. 의료인 대상 자살예방 교육을 도입하여 일차 의료인을 통해 자살 고위험 군을 선별하고 이들에게 약물 및 상담 치료 등의 적절한 치료를 제공할 경우 자살률을 감소시킬 가능성이 있으므로, 이에 대한 논의가 필요함(한국보건사회연구원, 2010). 

나. 알코올 중독

(1) 해외 연구현황

◯ 전 세계적으로 알코올 중독자의 수는 약 2억 3,700만 명이며, 이중 약 18%는 알코올 중독으

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로 인한 자살 사망자로 보고되고 있음(WHO, 2018). 여러 해외 선행연구는 알코올 섭취 및 고위험음주와 자살과의 연관성을 발표하였으며, 알코올 의존증이 높을수록 자살 시도 위험이 상승하는 경향을 보임(Xuan et al, 2016). 실제로 알코올 남용자의 생애 자살률은 약 7%로 보고되고 있으며 특히 고위험 음주자의 자살률이 높음(Akechi et al, 2006; Nakaya et al, 2007).

◯ 알코올이 자살에 영향을 미치는 기전을 살펴보자면, 우선 알코올 섭취 시 알코올의 신경생물학적 영향으로 인해 충동적 행동, 판단력 부족, 위험 감수 등의 행동을 보일 가능성이 높아지는데, 이는 자살 위험을 높이는 경향이 있음(Holmgren & Jones, 2010). 또한 장기적인 알코올 남용은 재정적 어려움, 가족 붕괴, 사회적 고립 및 신체적 건강문제 등과 같은 사회적 위험 요인과도 관계가 있음. 물론 이와 반대로 정신질환, 사회적 배제, 낮은 사회경제적 위치와 같은 요소들은 개인을 알코올 섭취 및 남용에 노출시킬 가능성이 있음(Suicide Prevention Australia, 2011). 

◯ 개인이 아닌 인구집단 수준에서 알코올과 자살의 연관성을 살펴보면, 1인당 알코올 구매량 혹은 섭취량 역시 자살률과 관계가 있는 것으로 여러 국가에서 보고되었으며(Xuan et al, 2016), 이외에도 폭음 문화와 같은 인구집단의 일반적인 음주문화도 자살 위험과 관련이 있는 것으로 발표됨(Radvodovsky, 2009). 따라서 알코올 남용을 방지하고 알코올로 인한 자살 사망을 낮추기 위해서는 효과적인 알코올 정책의 시행이 중요함(Xuan et al, 2016).

(2) 해외 정책사례

◯ 대부분의 국가 알코올 정책의 목표는 알코올 남용을 예방하고 알코올로 인한 부정적인 영향을 감소시키는 것임. 흔히 시행되는 정책으로는 음주 과세, 음주 연령 제한법 도입, 알코올 판매점의 밀도(outlet density) 제한, 알코올 장애관련 치료 제공 등이 있음(Xuan et al, 2016). 

◯ 선행연구는 음주 과세와 자살 사망률이 역관계성을 보인다고 발표함(Xuan et al, 2014; Babor et al, 2010). 또한 Callaghan 외의 분석에 따르면, 음주 제한 연령을 폐지할 경우 청년층의 자살 시도로 인한 입원률이 통계적으로 유의하게 상승함(Callaghan et al, 2013). 마지막으로 Giesbrecht 외의 연구에 의하면 알코올 판매점의 밀도가 높아질수록 남성에서 알코올 관련 사망이 증가하는 경향이 있음(Giesbrecht et al, 2014). 

◯ 구체적인 자살 사망 관련 알코올 정책의 대표적인 예시로는 호주의 National Preventive Health Strategy가 있음. 이 정책은 음주 광조 제한 및 음주 과세를 통한 알코올 섭취량 감소 및 치료의 접근성 향상을 목표로 삼고 있음. 하지만 이 정책은 아직 뚜렷한 효과를 보이고 있지 않아 보다 효과적인 전략을 시행하기 위한 추가적인 연구 및 효과평가의 필요성이 제기됨(Suicide Prevention Australia, 2011). 

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(3) 국내 연구 및 정책 동향

◯ 2011년 정신질환실태 역학조사의 결과에 따르면, 국내의 알코올사용 장애의 평생 유병률은 남자 20.7%, 여자 6.1%, 전체 13.4%로, 남자 다섯 명 중 한명은 알코올 사용 장애를 경험한 적 있는 것으로 분석됨(서울대학교 의과대학, 2011). 특히 알코올 중독 관련 현황을 보면, 알코올 의존(내성과 금단증상)과 남용(내성과 금단증상 없으나 일상생활에 부적응 발생)이 포함된 알코올 사용 장애 평생 유병률은 12.2% (남자: 18.1%, 여자: 6.4%)이며, 18세 이상 64세 이하 성인의 평생 유병률은 2001년 15.9%, 2006년 16.2%, 2011년 14.0%, 2016년 13.4%로 감소추세에 있음(보건복지부, 2017). 

◯ 음주는 자살과 밀접한 연관성을 보이는데, 실제로 우리나라의 전체 자살률은 음주율과 비례하며 상당수의 자살자가 자살 전 음주한 상태인 것으로 파악됨(알코올사업지원단, 2011).

◯ 이홍식 외에 의하면 알코올 중독 환자의 40%가 한 번 이상 자살을 시도했으며, 약 7% 정도가 자살로 사망함. 정신의학적으로 볼 때 알코올중독환자들은 우울증에 걸릴 확률이 높은데, 알코올 소비량이 세계적으로 많은 한국의 음주문화는 높은 자살률과 연관성이 있을 가능성이 높음(이홍식 외, 2007). 

◯ 이외에도 박아름의 연구에 의하면 자살 생각을 가진 알코올중독자는 전체의 약 41.1%로, 알코올중독자의 자살생각이 일반 인구에 비해 약 3배 높음. 특히 음주의 심각성은 자살 생각에 직접적인 영향을 미치는 요인으로 확인됨(박아름, 2014). 마찬가지로 최혜금 외의 연구 역시 알코올 사용 장애를 가진 음주 군이 정상 음주 군에 비해 자살 생각의 위험이 약 2.6배 더 높은 것으로 보고함(최혜금 등, 2016). 

◯ 알코올 중독 예방 및 국가음주폐해 감소를 위해 정부는 국가알코올종합대책인 ‘파랑새플랜 2010’을 발표하였으나, 정책집행을 위한 후속조치가 시행되지 않아 실효성 있는 사업이 이루어지지 않음(알코올사업지원단, 2010). 현재 우리나라의 자살예방국가행동계획에는 자살을 부추기는 과도한 음주 문화 해소를 위해 미디어음주장면 가이드라인 제시만이 포함됨. 

◯ 알코올과 자살과의 밀접한 관계를 고려하였을 때, 보다 구체적인, 근거 기반의 알코올 정책 도입이 필요할 것으로 보임. 하지만 효과적인 알코올 정책의 기반이 되는 알코올과 자살 사망의 연관성에 대한 연구는 현재 부족한 실정이며, 이의 핵심적인 원인 중 하나는  알코올 섭취량, 행태 및 문제행동 등을 대변하는 Alcohol Use Disorders Identification Test (AUDIT)와 자살 사망 변수를 동시에 파악할 수 있는 자료의 부재임. 

◯ 현재 음주와 자살의 연관성을 파악하는데 사용할 수 있는 자료로는 국민건강영양조사, 한국복지패널, 고령화연구패널조사, 국민건강보험공단 표본코호트 등이 있음. 국민건강영양조사를 이용하여 음주 빈도, 1회 평균 음주량 및 AUDIT 점수를 측정할 수 있어 비교적 자세히 음주행태를 분석할 수 있음. 하지만 국민건강영양조사는 자살 사망에 대한 변수가 포

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함되지 않으므로 자살 생각, 계획 및 시도로 자살 사망을 대체해야하는 제한점이 있음. 국민건강보험공단 표본코호트를 사용할 경우 알코올 관련 질환(예: alcoholic liver disease) 발생 및 자살 사망에 대한 기록을 확인할 수 있음. 하지만 주요 사회학적 자살 위험요인 관련 변수 등은 측정이 불가능함. 

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2. 사회 분야: 사회경제적 영역에서의 자살 연관 통계 검토

◯ 교육수준, 소득 등은 총괄적인 지표로서 의미를 갖지만 자살의 직접적인 계기로 작동하는 것은 아님. 즉 낮은 학력 수준이 자살을 유발하기 보다는 거기에 집약되어 있는 특정한 상황들일 것임. 예를 들어 가난과 자살의 관계를 살핌에 있어 가난은 여러 경로를 통해 자살과 연결되며, 가난이 한국 현실에서 자살의 조건으로 실현되는 구체적인 상황들을 살피는 것이 필요함. 음식이나 의료에 대한 접근 기회, 거주 공간의 유형, 열악한 생활환경, 기초 생활수급자 상태와 같은 취약성이 정의되는 것이 그 실천적 함의와 가능성을 선명하게 보여줄 수 있음. 따라서 이 연구는 한국 사회의 사회경제적 영역에서 취약성이 극대화되고 인간적 조건이 부정되면서, 동시에 복지적 접근이 어렵거나 간과되고 있는 상황들을 드러내고자 함. 

가. 다중채무와 자살

(1) 국내 현황

◯ 경제적 취약성은 자살에 깊게 연관됨. 자살시도의 경험이 있는 일반과 외래 환자 대상으로 자살을 시도하게 된 원인을 조사한 보고서에 따르면 현재 질환, 가족갈등, 직장 생활, 생활환경 문제, 취업문제, 대인관계 문제 등 여러 자살 시도원인 중 경제적 어려움 요인이 28.7%였고, 특히 남성의 경우 42.9%를 자살시도 원인이 된다고 응답하여 원인 요인 중 응답 비율이 가장 높았음(정진욱, 2010). 

◯ 경찰청 조사 결과에서도 정신적 문제 (36.2%), 경제생활문제 (23.4%), 신체질병 (21.63%)로 자살의 주요 동기에 경제적 생활 문제의 비중이 컸으며(경찰청, 2016), 경제적 어려움으로 인한 자살의 비중이 지속적으로 상승하고 있음. 구체적으로, 성별‧연령‧직업‧지역에 따라 자살의 동기는 다소 차이가 있었는데 남성의 경우 정신과적 문제(29.9%) > 경제생활 (28.3%) > 신체질병 (22.0%) 이었고, 특히 40세 이하 50세 이하는 다른 연령층 (20세 이하, 30세 이하 혹은 61세 이상) 군과 다르게 경제적인 문제가 주요 자살 요인 비중이 높았음. 

(2) 해외 정책사례

◯ 영국의 지역자살예방계획 수립 지침서에서는 부채와 같은 경제적 요인으로 경제적 어려움을 겪는 사람 중 특히 중년 남성에 초점을 두어 사회적 고립, 마약과 알코올과 함께 중점과제로 채택하여 이들 취약계층에게 주택을 제공하고(homeless services to provide), 재정 및 부채를 지원하는(promote financial and debt counselling support)부분에 대해 제시하며, 지역기반 접근에 대한 정보와 경제적 특성과 자살과 관련된 연구 결과들을 제시하여 근거에 기반한 사업이 될 수 있도록 제안하고 있음(PHE, 2016).

◯ 일본의 자살대책지원센터 라이프링크 (自殺対策支援センターライフリンク)는 2004년 발족

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한 비영리기구법인으로 2013년 자살실태백서를 발간하였음. 각 지자체 (광역, 기초 지자체)의 자살대책을 자체적인 평가지표를 통해 조사한 결과 대책기반과 개별시책으로 나누어 평가체계 표를 제안하였고, 중점시책 6: 사회적인 대처 부분에서‘실업대책‧취업 지원을 실시’, ‘경영자 지원을 실시’, ‘다중 채무자 지원을 실시’, ‘생활 안정화 지원을 실시’, ‘자살 보도 가이드라인 작성 등을 언론에 호소’ 내용을 다루고 있어, 다중 채무자에 대한 지원을 실시하고 있음. 

◯ 또한 국내에서 중년 남성(40세 이하 50세 이상)에게 있어서 경제적 요인이 자살률의 요인이었다면, 일본의 연구에서도 언급되고 있음(Kameyama, 2011). 

◯ (금융기관) 소비자가 대금업자 등으로부터의 채무 변제에 궁핍했을 경우의 대응으로서는 우선은 정중한 사정의 청취와 채무정리 등도 포함한 해결 방법의 검토가 필요하지만, 그 후에 자기파산 ‧ 개인재생 등의 채무정리와 함께 어디가지나 다중채부 문제 해결의 하나의 선택사항으로서 세이프티 넷 대부 제공에 대해서도 검토가 필요함. 또, 세이프티 넷 대부를 실시하는 경우에서도, 대응의 전제로서 정중한 사정의 청취와 구체적인 해결 방법의 검토가 충분히 행해지도록, 상담 청구와 세이프티 넷 대부를 실시하는 주체와의 네트워크의 구축이나 제휴의 촉진이 필요함.

◯ (지방 자치 단체) 지방자치단체(특히 시읍면) 는, 주민으로부터 가장 가까워서, 주민과의 접촉 기회, 또한 현재 소비생활센터나 기타 상담창구에서 다중채무상담에 응하고 있는 곳도 있어 소비자기본법상 국가와 함께 소비자정책의 담당자이므로 ‘다중채무자에 대한 대응은 자치단체 스스로의 책무’라는 의식을 가지고, 상담창구에서 적극적으로 대응하는 것이 바람직함. 또한 지방자치단체는 여러 부서에서 주민들과 접촉할 기회가 있으며, 다중채무자의 발굴 (발견)에 대해 다른 주체에 비해 기능 발휘를 기대할 수 있다고 생각됨. 또, 생활보호나 아동 학대 대책 등, 다중 채무자가 가질 수 있는 다중 채무 이외의 문제도 포함해 종합적으로 문제를 해결하는 역할도 기대할 수 있다고 생각할 수 있음. 

나. 사회적 관계망과 자살

(1) 국내 현황

◯ 한국 사회의 높은 자살률과 사회적 자본이 밀접하다는 점은 이론의 여지가 없어 보임(Chan et al, 2015). 한국의 빈약한 사회적 관계망은 OECD 국가에서 가장 낮은 사회적 지지로서 보고되기도 하고(OECD, 2017), 중년 남성의 높은 고독사로 나타나기도 함[보건복지부, 2015 에서 집계한 2015 무연고자 사망자(고독사 현황)]. 실재 1인 가구나 독거인 경우 다른 어떤 가구형태보다 자살과 연관성이 높으며, 그 과정은 사회적 자원의 획득에서 어려움을 겪거나(이은정, 2003), 사회적 고립(백학영, 2006) 등에 의해 매개되고 있음. 

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(2) 해외 연구현황

◯ 사회적 정서적 자원을 일컫는 사회적 자본(social capital)은 사회적지지, 통합(integration), 연결(connectedness) 등으로 파악되기도 함. 사회적 자본은 개인 혹은 집단이 그(들)가 속한 사회적 관계망을 통해 접근할 수 있는 개인적 혹은 집단적(지역사회) 자원의 양을 말함(Moore & Kawachi, 2017). 사회적 자본의 측정은 사회적 네트워크, 호혜성(reciprocity), 신뢰수준(trust), 지역사회 탄력성(community resilience), 참여와 권력이양(participation and empowerment) 등의 범주로 구체화됨. 이 중 사회적 지지는 사회적 자본의 네트워크 혹은 양상을 특수하게 의미하는 것이며(Poortinga, 2012; Poortinga, 2006), 사회적 지지와 건강의 연관성에 대한 연구는 고찰논문만 110편에 이를 정도임. 현대사회는 사회적 관계망은 SNS 공간이라는 새로운 장의 확대에도 불구하고, 사회적 관계망은 양과 질 모두에서 악화되고 있음 (Holt- Lunstad et al, 2010). 자살에 대한 사회적 자본의 완화효과는 독립적으로 혹은 사회경제적 수준과의 연관성하에서 다루어짐(Kawachi et al, 2004). 사회적 고립에 처할 가능성 (Berkes & Loss, 2013), 사회적 관계망, 가구구성 (Ryan and Smith, 2009) 뿐 아니라 결혼, 사회적 접촉, 낮은 사회통합 등과 같은 특이적인 상황 등(Fässberg et al, 2012)이 자살과 맺는 연관성에 대해 탐색되어옴. 사회적 관계망에 대한 해외 연구는 <표 13>에 제시됨.

(3) 해외 정책사례; 사회적 네트워크 강화를 위한 정책을 중심으로

◯ 앞서 살펴보았듯이 사회적 지지는 자살의 주된 원인으로 사회적 관계망으로부터 고립된 개인의 연결망을 회복하는 것은 관건적으로 중요함. 사회적 네트워크에서 단절된 개인에 대한 사회적 자원의 제공은 이를 어느 정도 완화할 수 있는 것으로 알려져 있음. 사회적 지지를 강화할 수 있는 자살예방 중재로는 전화상담, 응급 응답서비스 등의 효과가 밝혀져 있음(De Leo et al, 2002). 일본은 JAGES 연구 등을 통해 소위 Salons 이라고 불리는 공간을 통해 게임, 수놓기, 공예 등과 같은 노인 간의 다양한 자조모임을 조직하거나(Hikichi et al, 2017), 좀 더 큰 지역 사회 단위에서 기업, 가족 단위의 연결 양식을 개발하여, 지역 사회 

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주민의 참여를 유도하고, 이들을 관계망에 연결시키기 위해 다양한 방안을 시도하고(JSSC, 2017) 있음.

◯ 지역사회는 다양한 자원과 다양한 공간이 엮여있고, 개인과 개인, 개인과 단체가 연결되어 있는 장으로 볼 수 있음. 사회적 네트워크에 대한 지원은 지역사회를 개인적 삶의 범위의 일차적 확대 공간이라고 할 때 지역에 기반을 둔 전략이 가장 효과를 발휘할 수 있는 지점임. 실제 유럽, 호주 등 주민참여가 활발한 국가에서 지방정부의 주된 역량은 직접 서비스를 제공하는 역할과 더불어 사회관계망에 대한 정보를 제공하고 지역 구성원간의 협력과 흐름을 조직하는 것으로 평가됨. 많은 지역 정부는 예를 들어 연령별 가능한 레저 활동, 관내에 이용할 수 있는 정신보건 서비스 종류와 기관, 시니어 클럽을 위한 분기별 이벤트, 모임, 활동 소개 등을 주기적으로 알리고 있음[부록 3]. 

(4) 국내 연구 및 정책 동향

◯ 사회적자본과 자살의 연관성에 대한 연구는 크게 보아 지역사회의 요소 대신 개인적인 요소로 제한되어 왔음. 지역사회의 맥락적 의미가 한국사회에서 뿐 아니라 연구에서도 간과되어 왔다고 할 수 있음. 또한 개인적 측면에 대한 접근에서도 사회적 자본의 포괄적 특성이 종교, 이혼, 독거 등의 가구 구성에 집중되거나, 사회적 지지로서 파악되는 경우에도 생활환경 개선비와 사회보장비(김상원, 2010) 등으로 축소되어 파악되는 연구되는 경향이 많았음. 사회적 네트워크, 사회적 참여 (Karen Ra & Cho, 2013) 등 사회적 자본의 일부에 연구가 한정되거나, 이는 한국 사회의 사회적 관계망이 지역보다는 가족 중심으로 국한되거나 (Suh, 1992), 내부적 결속(bonding)을 강조하는 배타적 사회적 자본(김은미 & 배상수, 2012)이 주되었기 때문임. 사회적 자본이 여러 요인들의 전체적인 상호작용으로 작동한다고 할 때 이러한 연구들의 한계는 명백하며 지역사회가 갖는 다면적 특성을 파악하기 위해서는 사회적 관계의 밀접성과 같은 사회적 자본의 질적인 특성에 대한 이해가 필요함. 

◯ 한국사회에서 지역사회 혹은 마을에 대한 강조는 간간히 이루어져 왔으나, 재개발 논리에 밀리고 아파트라는 주거양식이 보편화함에 따라 자신이 속한 지역과의 유대 여건이 강하지 않은 상황임. 사회적 관계망은 집단 간의 교류와 협력적 차원보다 이해 관계적 측면이 강조되고, 지역을 기반으로 한 사회적 자본 역시 법과 기관 등의 제도적 장치에 대한 참여와 통제 수준의 강화라는 본래적 의미보다 자신이 속한 지역의 배타적 이익(주되게는 집값과 지대)이라는 공통의 이해를 중심으로 한 집단의 성격이 강함. 지역사회가 공동체라는 내부적 유대감와 결속을 특징으로 한다고 할 때 그에 기반을 둔 유형과 아파트라고 하는 한국에서의 거주 형태가 갖는 비지속적 단절적 유형에 맞는 사회적 자본으로 구분되어 모형이 제시되고 발전될 필요가 있음. 

다. 주거와 자살

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(1) 국내 현황

◯ 이노근(새누리당) 의원이 SH공사에서 받은 자료에 따르면 2011년부터 2013년까지 3년간 서울시 산하 SH공사가 관리하는 임대아파트에서 125명이 자살했다. 이노근 의원은 "임대아파트 주거환경과 입주자 자살이 관계가 있는지 서울시와 SH공사가 실태조사를 할 필요가 있다"라고 밝힌 바 있음 (2014.11.10. 연합뉴스).

◯ 임대아파트에서 발생하는 자살은 대개 재계약 탈락에 따른 임대아파트에서의 퇴거, 임대료를 비롯한 각종 공과금 문제 등 뚜렷한 위기를 겪는 상황에서 초래되기도 함. 그러나 이러한 위기는 임대아파트 거주자들은 한국 사회에서 가장 열악하게 살아가는, 즉 수시로 가장 어려운 상황에 놓인 사람들이 겪는 지속적으로 발생하는 어려움의 일부로 이해되어야 할 것 임. 또한 임대아파트는 재개발 과정에서도 높은 스트레스를 경험하게 되는데 얼마 전에도 재개발지역 세입자가 강제철거에 항의하며 자살하는 일이 발생함. 재개발 지역에서 자살은 드물지 않게 발생함에도 불구하고 우리 사회는 이에 대한 실태 파악이 이루어지지 않고 있음. 재개발 과정 특히 강제철거가 동반되는 경우의 스트레스 수준은 지속되는 철거의 위협, 철거의 순간에 받게 되는 트라우마 등은 인간으로서 견디기 힘든 정도이며, 자살 행동의 가능성을 높임. 강제철거 뿐 아니라 재개발 지역의 폭력성은 여러 형태로 인간의 존엄성이 심각하게 훼손시킬 수 있으며 (재개발 지정을 둘러싼 주민간의 갈등, 재개발 지정 철회로 인한 좌절, 철거 용역업체의 폭력적 행동 등), 이러한 스트레스가 높은 상황은 극단적인 결정의 가능성을 높임. 

(2) 해외 연구현황

◯ 미국에서 National Violent Death Reporting System에 참가하고 있는 16개 주를 대상으로 진행한 연구 결과, 서브프라임 모기지 부실 위기 사태 전후의 자살률을 비교했을 때 그 전(2005)에 비해 후(2010)에 압류와 강제퇴거에 뒤이은 자살이 100% 이상 증가하였다고 보고하고 있음(Fowler et al, 2015).  

◯ 미국의 주를 단위로 한 2006- 10년 사이의 압류율의 자살률에 대한 회귀분석에서도 유의한 연관성이 밝혀졌으며, 특히 중년(46세- 64세)에서 영향이 큰 것으로 보고됨(Houle & Light, 2014), <그림 14>. 비슷한 맥락의 압류(eviction)와 자살의 연관성에 대한 연구가 개인단위에서 확증되었는데 이는 복지수준이 높다고 알려진 스웨덴에서의 대규모 연구를 통해 보고되어 상당한 파장을 일으킴. 2009- 12년 사이 법원으로부터 압류 영장을 받은 모든 스웨덴인 23000명의 자살률은 일반 인구에 비해 4.42배 높았음. 이에 대해 저자들은 집에 대한 압류의 경험은 사회적 적응에 대한 트라우마를 크게 남기는 수치스러운 기억이므로, 이 과정에 관여하는 직업은 인간의 기본권에 대한 충분한 이해를 갖추어야 함을 강조하고 있음. 

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(3) 해외 정책사례

◯ 영국에서는 사회적 긴축과 더불어 임대료 지불, 강제 퇴거 등으로 인한 공공주택 거주자들의 정신건강이 악화되고 자살률이 올라감. 이에 공공주택 관계되는 임대 관리 사무소의 모든 직원, 즉 임차인을 관리하는 사무실 직원 뿐 아니라, 유지보수 팀의 직원들까지 임차인들의 생활고와 이에 따른 심리 문제들을 다룰 수 있는 훈련을 진행함. 관리 사무소의 직원들은 평소에 행하던 직무 외에 임차인의 고충과 그로 인한 고립, 정신 심리적 압박까지 평가할 수 있는 준비를 하고 있음. 

◯ 미국에서 주거 안정은 아래 CDC의 자살예방 전략에서 요약하고 있는 것처럼 미국 자살 예방의 주요한 프로그램으로 자리 잡고 있음<표 14>. 압류나 강제퇴거의 충격을 최소화하기 위해 다양한 형태의 지원 프로그램을 제공함. 당사자들을 가능한 주거를 유지할 수 있도록 돕거나, 저렴한 대안적인 거주 옵션의 제공, 이용할 수 있는 정부 보조금의 소개, 대출 변경(loan modification program), 이사 계획(move- out planning), 금융상담 등을 제공함. 이완 관련된 가장 큰 규모의 정부 재정지원은 Neighborhood stabilizing program이며, 압류되거나 포기된 집의 구매, 재판매, 재건축 등의 방법으로 마을의 황폐화와 집값의 갑작스런 하락을 막도록 하고 있음.

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(4) 국내 연구 및 정책 동향

◯ 국내에서는 재개발과 관련한 강제철거, 고시원을 전전하는 중년 인구들에 대한 간헐적인 언론 기사 등은 접할 수 있으나 그 실상에 대한 접근은 제한적 임. 김영욱과 김주영(2016)은 영구임대아파트와 판자촌의 자살률을 비교하여 임대아파트의 자살률이 판자촌의 그것보다 높다고 보고하고 있음. 이때 자살자 수의 집계는 대략적인 추정에 의존하고 있음. 자살자 수는 구청 및 경찰청의 자료에서, 분모는 임대아파트/판잣집의 세대수와 평균 세대 당 가구 수를 곱하여 얻음. 이렇게 생성된 간접적인 수치로 실재 규모를 추정하는 것은 우리나라의 자살 통계의 한계를 보여주는 것임. 

라. 사회경제적 영역과 자살 영역에 대한 소결

◯ 사회경제적 조건과 자살의 관련성에 대한보고는 매우 다양함. 이러한 사회 경제적 취약성을 완충하는 제도적 장치들이 필요함. 미국에서 진행된 한 연구에 따르면 가구의 재정을 보조하는 연금이나 장애 보험, 실업급여, 의료급여, 가족지원 등의 공공지출에 의한 주별(state level) 공적이전(total transfer payment)은 주별 자살률과 연관됨을 밝힘. 이런 유형의 지출을 국가차원에서 늘려 연간 일인당 45달러를 더 지출할 경우 약 3000명의 자살이 감소할 것으로 예측하고 있음(Flavin & Radcliff, 2009). 

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표 . 미국 CDC의 자살예방 중재 전략(CDC, 2017)

Strategy	Approach
Strengthen economic support	• Strengthen household financial security • Housing stabilization policies
Strengthen access and delivery of suicide care	• Coverage of mental health conditions in health insurance policies • Reduce provider shortages in under served areas • Safer suicide care through system change
Create protective environments	• Reduce access to lethal means among persons at risk of suicide • Organization policies and culture • Community- based policies to reduce excessive alcohol use
Promote connectedness	• Peer norm programs • Community engagement activities
Teach coping and problem- solving skills	• Social- emotional learning programs • Parenting skill and family relationship programs
Identify and support people at risk	• Gatekeeper training • Crisis intervention • Treatment for people at risk of suicide • Treatment to prevent re- attempts
Lessen harms and prevent future risk	• Post intervention • Safe reporting and messaging about suicide

◯ 위에서 살펴본 예들에서 사회경제적 분야의 자살에 대한 개입은 첫째, 보편적 복지정책의 일환(예: 공적이전)으로, 둘째, 그 자체 금융 혹은 주거 정책(예: neighbourhood stabilizing program)으로, 셋째, 정신문제에 대한 반응성을 높이기 위한 정신보건을 제공(예: 영국의 공공주택 직원들을 대상으로 한 정신보건 훈련)하는 것으로 유형이 구분됨. 삶의 위기적 순간들에서 무언가가 작동한다는 것이며, 그것은 반드시 보건이거나 보건과 연관될 필요는 없음. 이런 계기들을 자살의 관점에서 망라하고 여러 형태로 관여할 수 있는 사회적 장치를 촘촘하게 마련하는 것이 중요함. 

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3. 노동 분야

◯ 2018년 10월 현재 한국의 취업자 수는 2천7백만 명을 넘음. 15세 이상 국민 중 61.2% 가 고용된 노동자로서 경제활동을 하고 있음. 노동은 경제적 수단을 얻는 원천이자 자기를 실현하는 장임. 일터는 사회적 관계가 형성되는 장소이자 가장 많은 시간을 보내는 곳이기도 함. 때문에 노동, 일터, 직업과 관련된 물리적, 경제적, 사회심리적환경은 그 안에서 삶을 영위하는 노동자들의 신체적, 정신적 건강에 크나큰 영향을 미침. 일터의 작업환경(물리적, 화학적, 생물학적, 심리사회적)은 신체적 질병을 야기할 뿐 아니라 노동자들의 정신을 소모하여 정신적인 우울감을 유발함. 이는 다시 직장에서의 결근, 프리젠티즘(몸이 아프지만 일을 지속하는 경우), 업무관련 사고 발생으로 이어지고, 노동자의 고용 상태와 커리어에 악영향을 미치며, 질병, 사망, 자살과 같은 치명적 결과로 연결됨<그림 15>. 

◯ 자살 예방을 위한 정책과 중재 프로그램들은 따라서 노동과정의 다양한 요인들이 함께 작용하여 자살로 이어지는 기전을 세밀하게 점검해야 함. 전 세계에서 노동시간이 가장 길고 고용은 불안하며 고용자와 피고용자의 힘이 불균등한 한국사회라면 더더욱 그러함. 

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◯ 사회적으로 잘 알려진 업무 관련 자살사건들이 노동환경과 자살의 관계를 잘 보여줌. 2017년 광주의 집배원과 2018년 웹디자이너의 자살은 장시간 노동이 다른 업무 관련 요인들과 합쳐져 발생함. 실적을 빌미로 한 과중한 노동 강도는 한 대기업 외주 콜센터 현장실습생을 자살로 몰고 갔으며, 일터의 괴롭힘과 인권침해는 새내기 간호사와 노조 간부로 하여금 스스로 삶을 중단하는 선택을 하게 함. 경찰통계연보(경찰청 2017)에 의하면 2016년 전체 자살자 13,020 명 가운데 514명 (약 4.0%)이 직장 및 업무상의 문제가 자살동기로 작용한 것으로 나타남. 이 통계는 하나의 자살사건에 하나의 동기만을 부여함. 그러나 자살에 이르는 과정에는 복수의 요인들이 복잡하게 얽혀서 작용한다는 점을 고려하면, 배타적인 범주로 자살동기를 구분하기는 어려워 보이며, 실제 노동환경에서 발생하는 요인들이 관여하는 자살사례는 훨씬 많을 것으로 추측할 수 있음. 또한 국가나 지역 단위의 경제상황, 특정 업계의 경기, 전반적인 기업 문화 수준, 노동시장에서 공급과 수요의 불균형 등 다수의 노동자들에게 영향을 미치는 외부적 요인을 고려하지 않은 채 개인적 수준의 동기를 분류하는 것은 자살 예방을 위한 원인 추적에 도움을 주지 못할 것임. 

◯ 자살예방을 위한 정책과 프로그램을 고려할 때, 우선 한 사회 안에서 자살이 발생하는 상황을 포괄적으로 이해할 필요가 있음. 평면적인 통계 수치에서 얻을 수 없는 자살사건의 정치, 경제, 문화, 심리적 맥락을 이해해야 함. 자살률은 지역 간, 계층 간, 성별과 세대 간 다르게 분포하며 시간에 따라 변동함. 이러한 변이는 자살을 예방하고자 하는 사회가 주목해야 할 실마리를 제공할 뿐만 아니라, 자살을 하나의 사회적인 사건으로 파악해야 함을 시사함. 누군가는 삶을 지속하는 곳에서 누군가는 죽음을 선택하는 차이를 무엇으로 설명할 수 있는지를 천착하여 개별 사건들 속에 자리 잡고 있는 공통의 진실에 접근해야 함. 일터에서 혹은 노동시장에서 개인들이 부딪히는 하나하나의 사건들과 환경은 개인의 정신적 건강에 심대한 영향을 미침. 생존수단의 획득이라는 절박한 문제이기 때문이고, 직업적인 자기실현이라는 실존적 문제이기 때문임. 그간의 연구들에 의해 노동환경이 개인의 생존과 실존을 황폐화하여 스스로 삶을 중단시키는 상태까지 몰아갈 수 있다는 많은 역학적 근거가 축적되어 있음.

가. 해고와 불안정 노동

(1) 국내현황

◯ 쌍용자동차 해고노동자와 가족들의 자살 및 자살생각: 2009년 사측의 대량 해고로 시작된 쌍용자동차 사건은 2018년까지 30명의 자살이라는 비극으로 이어짐. 해고노동자 배우자의 자살도 4명에 이름. 파업과 구속 과정에서 겪은 트라우마와 생활고, 사회적 고립과 낙인에 의한 결과임. 자살에 이르지 않은 경우에도 우울감, 수면장애, 자살생각 등 심각한 정신건강 증상들을 경험한 것으로 나타남. (관련기사 쌍용차의 29번째 죽음 -  2017년 7월 12일 한

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겨레21; 쌍용차 해고자 아내 절반은 자살생각-  2018년 9월 6일 한겨레) 이 사건은 해고가 살인이라는 말이 단지 수사적인 표현이 아니라 해고노동자의 삶과 정신을 무너뜨릴 수 있다는 것을 보여주는 대표적인 사례임. 복직을 기대하며 협상과 투쟁을 반복하던 해고노동자들은 경제적 어려움과 사회적 고립, 가족관계의 단절을 경험하였고, 시간이 길어지고 희망고문이 계속될수록 정신적인 우울감을 경험함. 해고가 경제적, 사회적 삶을 와해시키고 정신을 소진하여 삶을 유지하기 어려운 상태로 몰고 가는 흐름이 반복적으로 나타나는 것임.  

(2) 국내외 연구현황

◯ 실업과 자살의 관련성에 대한 생태학적 연구들이 국내외 자료를 이용해 진행된 바 있음. 한국의 2008년 경제위기 전후 전 인구집단 자살률을 비교한 한 연구의 결과는 실업률의 악화가 자살률의 상승과 연관되어 있는 것으로 나타남(Chan et al, 2014). 자살률 상승은 실업률 상승에 2~3개월의 시차를 두고 나타났으며, 모든 성별과 연령에서 관찰됨. 실직자 뿐 아니라 고용상태에 있던 사람들에서도 자살률이 높아짐. 국가수준의 실업률의 상승은 구조조정에 의한 고용불안정과 노동 강도 증가를 야기하고, 다시 우울증 발생 증가와 기존 정신질환의 악화로 이어져 자살률 상승으로 연결되는 것으로 이 연구는 추정하였음. 직업별로는 관리자, 사무직, 판매/서비스직의 자살률 상승이 다른 직종보다 더 현저한 것으로 나타남. 

◯ 2005 ~ 2011년 사이 한국의 지역별 사회경제 지표와 자살률 변화를 분석한 결과 시군구 단위의 고용률이 자살률의 상승과 관련 있다고 보고됨(이민아 & 강정한 2014). 시도 수준의 지역별 분석에서는 고용률과 자살률의 관계가 유의하지 않았으나 좀 더 세밀하게 들여다 본 시군구수준의 분석에서는 유의한 관련성을 보여서 동일한 광역시도 내에서도 이질적인 고용률을 가진 지역들이 함께 있음을 시사. 

◯ 한국의 복지패널조사 자료를 이용한 연구(Kim et al, 2017)에서는 직업안정성과 정신적 증상 -  우울증 삽화와 자살생각 -  이 높은 관련성을 보이며 특히 남자에서 관련성이 높은 것으로 드러남. 직업안정성이 높다고 주관적으로 인식하는 군에 비해 직업안정성이 낮다고 인식하는 군의 우울증 보정 위험비(Adjusted hazard ratio)는 남자에서 1.27(95% 신뢰구간 1.01- 1.60), 여자에서 1.50(95% 신뢰구간 1.12- 1.99)으로 나타남. 자살생각의 보정 위험비는 남자에서 3.25(95% 신뢰구간 1.72- 6.16), 여자에서 1.55(95% 신뢰구간 0.93- 2.59)였음. 직업안정성이 노동자 정신건강의 궁극적인 개선책이라고 이 연구는 주장함.  

◯ 해외 연구로 실업 기간과 자살률의 연관성이 보고된 바 있음. 1980년 이후의 16개 연구를 종합한 메타분석 연구에서는 처음 5년까지 실업기간이 길어질수록 자살률이 상승하였으며, 이후 16년까지 상승된 상태가 지속된 것으로 나타남(Milner et al, 2013).     

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◯ 한편, 불안정한 고용형태와 자살의 연관성 또한 연구된 바 있음. 비정규직 노동자의 자살시도나 자살생각이 정규직 노동자보다 높다고 보고된 바 있으며(Min et al, 2015), 여성 비정규직 노동자가 정신질환에 이환될 가능성이 여성 정규직 노동자에 비해 높다는 연구 결과도 있음(Kim et al, 2008). 

나. 비정규직 노동

(1) 국내 현황

◯ 비정규직 노동자 자살 사건: 비정규직 노동자나 파견노동자는 상시적인 고용불안과 함께 임금과 복지혜택 면에서 정규직과 차별을 받고 있음. 이들을 보호하기 위한 법률로 파견근로자 보호 등에 관한 법률(파견법)과 기간제 및 단시간근로자 보호 등에 관한 법률(기간제법)이 있으나 쪼개기 계약, 혹은 2년간 고용 직전 해고 등과 같은 방법으로 법조항을 무력화하려는 편법이 만연함. 해고된 불안정 노동자들은 해고로부터 비롯되는 고통과 더불어 정규직 전환이라는 희망의 좌절이 불러오는 충격을 겪음. 2013년 현대자동차의 파견노동자 자살사건 (관련기사 “현대차 비정규직 노동자 자살" -  2013년 4월 13일 한겨레)은 파견법망을 피하기 위한 회사 측의 편법에 의해 정규직 전환의 좌절과 해고가 자살로 이어진 사례. 2014년 중소기업중앙회에서 해고된 비정규직 노동자의 자살사건 (관련기사 “자살한 중기중앙회 비정규직女는부당해고” -  2014년 12월 1일 한국일보) 은 쪼개기 계약 후의 해고가 자살로 이어진 사례임. 해당노동자는 재직 시에 간부 등으로부터 여러 차례 성추행을 당한 것으로 알려졌음. 이러한 사건들은 불리한 지위로 인해 직장 내 차별과 인권침해, 그리고 만성적인 고용불안에 노출되는 불안정노동자들이 정신적인 고통이 극단적인 선택으로 이어질 수 있음을 보여주는 사례들임.   

(2) 국내외 연구현황

◯ 여러 국내외 연구는 비정규직 근로와 자살의 관련성에 대해 보고하고 있음. 특히 비정규직 대부분의 비정규직 근로자는 정규직 근로자보다 소득이 낮고, 승진기회가 적으며 고용이 불안정한 경향을 보여 자살 위험이 정규직 노동자 대비 높은 경향을 보임(Artazcoz et al, 2004; Saloniemi et al, 2004). 

◯ 구체적으로 비정규직 노동자의 자살 시도 및 생각 경험 비율이 정규직 노동자보다 높다고 보고된 바 있으며(Min et al, 2015) 이외에도 여성 비정규직 노동자의 정신질환 이환 위험이 정규직 노동자보다 높다는 연구결과가 발표됨(Kim et al, 2008).

다. 과로

(1) 국내 현황

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◯ 에스티유니타스 웹디자이너: 2018년 1월 중견 인터넷강의업체인 에스티유니타스의 웹디자이너가 자살하는 사건 발생함 (관련기사 -  “직원자살 에스티유니타스 유족 ”사과 없고, 증거자료도 삭제했다“ 2018년 4월6일 중앙일보). 2년 8개월 근무기간 동안 주12시간 이상 연장근로한 주가 46주에 이를 정도로 장시간 노동에 시달렸음. 평일야근 뿐만 아니라 주말에도 회사 고객 행사에 동원되었음. 장시간 노동과 업무스트레스로 인해 우울증이 악화되고 공황장애가 나타나 한 달간 휴직을 하였지만, 복귀 후 아무런 보호조치나 근무환경의 변화 없이 휴직 전과 동일한 강도의 노동을 지속함. 유족과 대책위원회의 요구로 회사 측은 2018년 6월 책임을 인정하고 사과함. 또한 법정노동시간 준수, 업무시간 외 업무지시, 과외업무 금지, 직언 대상 심리상담 및 치료지원, 근무환경 및 고충처리를 위한 고충처리센터 운영 등을 약속함.

◯ 서광주 우체국 집배노동자: 2017년 9월 서광주우체국의 집배노동자가 자택에서 자살함. 배달 중 교통사고를 당하고 치료하던 중 조기 근무 복귀를 종용 당했던 그의 유서에는 “이 아픈 몸을 이끌고 출근하라네. 사람 취급 안하네..”라고 쓰여 있었음. 그보다 두 달 전에는 안양우체국의 집배노동자가 우체국 앞에서 분신을 시도하여 사망함. 2013년의 한 조사에 따르면 집배노동자들의 주당 평균 노동시간은 60시간에 육박하고, 명절 때에는 80시간을 넘어가기도 했음. 이 때문에 2012년부터 2017년까지 우정사업본부에서 218명의 노동자가 사망하였는데, 이 중 34명이 자살이었음.  

(2) 국내외 연구 현황

◯ 한국의 국민건강영양조사 자료를 이용하여 노동시간과 자살생각을 분석한 연구(Yoon et al, 2015)에서는 장시간 노동을 하는 사람이 자살을 생각하는 경향이 큰 것으로 나타남. 주당 평균 52시간미만 일하는 노동자들과 비교한 60시간 이상 일하는 노동자들의 자살생각 교차비(Odds ratio) 는 남자의 경우 1.36(95% 신뢰구간 1.09- 1.70), 여자의 경우 1.38(95% 신뢰구간 1.11- 1.72)이었음. 장시간 노동이 저소득과 결합되면 이런 경향은 더 강하게 드러남. 장시간 노동(60시간 이상)을 하면서 소득이 낮은 사람들은 52시간미만 일하면서 소득이 높은 사람들에 비해 자살을 생각하는 교차비는 남자에서 2.01(95% 신뢰구간 1.46- 2.76), 여자에서 1.66(95% 신뢰구간: 1.22- 2.27)임. 국민건강영양조사 자료를 이용한 또 다른 연구(Kim et al.2013)에서는 장시간 노동과 우울증상이 연관되어 있으며 양- 반응 관계(dose- response relationship)가 있음을 밝힘.

◯ 미국의 종적 조사 데이터인 Mid- life Development in the United States 를 이용한 연구(Choi, 2018)는 장시간 노동이 중등도/고도의 자살생각과 종적으로 연관되어 있음을 보고하였음. 이 연구에서는 또한 노동의 시간적 연장뿐만 아니라, 업무중압감 (job strain) 도 자살생각과 연관되어있다는 결과를 밝힘. 업무중압감은 업무요구도 (job demands) 와 업무통제

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력 (job control) 사이의 불균형에서 비롯됨. 이는 업무량이 얼마나 과중한지, 그리고 노동자가 업무과정에서 전문기술을 사용할 수 있는지와 새로운 기술을 습득할 수 있는지에 의해서 결정됨(Karasek, 1990).

라. 인권침해

(1) 국내 현황

◯ 아산병원 간호사: 2018년 2월 아산병원 입사 6개월째인 신규 간호사가 자살함. 이 사건에는 수련과 업무 지도라는 명목으로 병원 내에 만연한 인격모독과 폭언이 작용했을 것으로 추정되고 있음. 의료기관은 동일직종 내에서 수직관계가 분명 보건의료산업노동조합이 2017년 말부터 2018년 초까지 실시한 의료기관 내 갑질 문화와 인권유린 실태조사에 의하면, 조사에 응한 6천여 명의 간호사 중 65.5% (4,000명) 가 욕설이나 모욕적 언사, 반말, 험담, 무시, 비하 등 폭언을 경험하였고, 폭행(10.5%), 성희롱과 성추행(13.0%) 등을 경험한 응답자도 다수인 것으로 드러남 (관련기사 -  “간호사, 갑질 문화 몸서리 10명 중4명 ‘태움’경험, 10.5%는 맞기도” 뉴시스 2018년 2월 23일). 사업주, 상사, 동료, 고객 등에 의해 일상적으로 행해지는 일터 괴롭힘은 정신건강의 악화와 자살 생각으로 이어짐. 2018년 한국직업능력개발원의 연구에 따르면, 직장 괴롭힘을 경험한 근로자 중 극단적 자살충동을 느낀 비율은 8.0%에 달함(서유진, 2018).

◯ 유성기업: 유성기업은 현대·기아자동차의 협력업체임. 2011년부터 시작된 폭력과 노조파괴 행위, 징계와 고소고발을 동원한 괴롭힘으로 노조간부 1명과 사측 구사대로 활동했던 다른 노동자 1명이 자살하는 일이 발생. (관련기사 -  폭력 노조? 유성기업 노조 파괴 8년 잔혹사 총정리 한겨레 2018년 12월 4일). 유성기업 조합원들은 노조법과 근로기준법을 위반하는 행위에 더해 징계와 고소고발, 손배소송 등 지속적인 괴롭힘을 당해 왔음. 총 고소고발 건수는 1천 건에 달하고, 노조간부들은 대부분 한 번 이상 고소고발을 당했으며, 3건 이상 당한 사람도 24명에 달함. 피소된 사람은 조사를 받고 법정에 서는 과정을 통해 스트레스가 누적되어 정신건강이 악화됨. 또한 회사측은 조합원에 대한 징계를 남발하여 2번 이상의 징계를 받은 조합원이 83명에 이르는데, 징계절차에서 조합원들은 많은 심리적 압박을 느낀 것으로 알려짐 (문송면 원진노동자 산재사망 30주기 추모조직위원회, 2018). 자살한 조합간부의 집에서는 개봉도 하지 않은 법원의 출두 명령서들이 다수 발견됨.

(2) 국내외 연구 현황

◯ 12편의 연구를 모아 2017년에 출판된 리뷰 논문(Leach et al, 2017)에 의하면, 대부분의 연구에서 일터 괴롭힘과 자살생각 사이에 유의한 상관관계가 있는 것으로 나타남. 포함된 연구들 중 일부는 대조군 없이 괴롭힘 피해자 중의 자살생각 빈도만을 보고하였거나, 혹은 

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단면연구라는 제한점을 갖고 있었으며, 전향적인 연구는 없었음. 그러나 모든 연구에서 일관된 방향의 결과 -  양의 상관관계-  가 보고되었다는 점에서 신뢰할만한 여지가 크다고 할 수 있음. 

◯ 또한, 안전보건공단의 근로환경조사 자료를 이용하여 수행한 연구에서는, 일터에서 당한 부당한 경험 -  성별, 장애, 나이 등에 의한 차별경험, 직장동료 혹은 고객에 의한 신체적 폭력이나 폭력위협, 괴롭힘이나 원하지 않는 성적 관심 -  은 우울증과 수면장애와 같은 정신건강 상의  증상들과 관련된 것으로 나타남(Min et al, 2014). 정신적 증상의 유병비(prevalence ratio)는 불안/우울이 3.1(95% 신뢰구간 2.1- 4.6), 수면장애가 3.0(95% 신뢰구간 1.9- 4.7)로 신체적 증상들 -  근골격계 통증, 복통, 전신피로 등 -  보다 높게 나타났으며 특히 여성의 유병비가 남성보다 높았음. 

마. 자살예방과 정신건강증진을 위한 국내외 중재프로그램 사례

◯ 노동환경에서 기인한 정신적 불건강은 당사자가 겪어야 하는 고통뿐만 아니라 기업의 생산성 저하로 이어짐. 정신적 증상을 갖고 있는 노동자는 업무 수행력이 저하되고 동료 및 상사와 잦은 갈등을 빚는 경향이 있음(OECD, 2015). 치료를 위한 직접비용과 더불어 장기 결근 등으로 인한 간접비용을 유발함. 이런 이유로 여러 국가들에서 노동자 정신건강을 증진하고 정신질환을 예방하기 위한 법제, 정책, 그리고 일터에서 실행할 수 있는 프로그램을 운영하고 있음. 중재프로그램 사례들은 기능과 목적에 따라 다음과 같이 분류할 수 있음: (1) 정신건강 모니터링 (2) 직장 정신건강증진 프로그램 (3) 고용지원 및 정신건강 게이트키퍼 (4) 직업별 자살통계생산.

(1) 정신건강 모니터링

◯ 덴마크의 노동환경의 사회심리적위험요인 평가 및 모니터링 프로그램: 덴마크는 사업장 단위에서 정신건강의 위험요인을 관리하도록 하고 있음. 덴마크의  노동환경법 (Working Environment Act) 은 노동환경의 심리사회적 위험요인을 관리하도록 사업주에게 의무를 부과하고 있으며, 노동환경국 (Working Environment Authority) 이 이를 감독함.  노동환경국은 24개 산업별, 직종별 지침도구(guidance tool)를 개발하여 사업주의 정신건강관리 의무를 감독하기 위하여 사용함. 지침도구에는 산업별, 직종별로 정신건강의 위험요인들이 기술되어 있고, 정신건강문제를 예방하기 위해 사업장에서 활용할 수 있는 자원들을 소개하고 있음. 지침도구는 근로감독 과정에서 널리 사용되고 있으며, 사업주들도 유용하다고 평가하고 있음.

◯ 일본의 직무 스트레스 검사제도: 일본은 경제 불황 이후 급증하는 자살에 대처하기 위해 2006년 ⌈자살대책기본법⌋과 더불어 ⌈노동자마음의건강유지증진을 위한 지침⌋을 제정

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해 본격적으로 노동환경과 관련된 자살에 관심을 기울이기 시작함. ⌈자살대책기본법⌋에서는 “사업주는 국가 및 지방공공단체가 실시하는 자살대책에 협력함과 동시에 그 고용하는 노동자의 마음의 건강의 유지를 도모하기 위해 필요한 조치를 강구하도록 노력해야 한다.”고 명시하여 자살 예방을 위한 사업주의 책무를 명시하고 있음.  2014년 말부터는 ⌈노동안전위생법⌋ -  한국의 산업안전보건법과 동등한 위상 -  개정안에  의거하여 스트레스 검사 제도를 도입하였음(안전보건공단, 2016). 이 법에 의하면 의사 등에 의해 실시되는 노동자의 심리적 부담 정도를 파악하기 위한 검사시행을 사업주의 의무로 규정하고 있음. 검사결과는 노동자의 동의가 없으면 사업주에게 제공하지 않음. 검사결과를 받은 노동자가 의사 상담을 희망할 경우에도 사업주는 상담을 제공해야 하며, 상담 신청을 이유로 불이익을 주는 것을 금지하고 있음. 또한 사업주는 상담 의사의 권고에 따라 근무 장소 변경, 작업 전환, 노동시간 단축, 야간노동 횟수 제한 등의 조치를 마련해야 함.   

 

(2) 직장 정신건강증진 프로그램

◯ 영국의 건설노동자를 위한 마음의 동반자 (Mates in Mind) 프로그램: ‘마음의 동반자' 프로그램은 정부의 인가를 받은 민간 프로그램으로 건설업 고용주에게 건설현장 노동자들의 정신건강과 정신질환에 관한 지침을 제공하고 가용한 지원에 관한 정보를 제공하고 있음. 이 프로그램은 세 가지 목표를 갖고 있음: (1) 업무와 관련된 정신적 (불)건강에 관한인식의 제고 (2) 정신건강과 관련된 서비스를 어디에서 제공받을 수 있는지, 언제 받아야 하는지에 관한 이해 증진 (3) 적극적인 의미의 일터의 안녕을 추구하는 문화를 통해 정신건강에 대한 침묵과 낙인 불식. ‘마음의 동반자' 프로그램의 사업영역은 다음과 같은 4가지 영역으로 구성되어 있음: (1) 인식 제고와 교육 프로그램: 정신건강 및 불건강의 인지를 위한 교육과 정신건강 응급처치를 위한 훈련 (2) 지침과 정보 제공: 도움 받을 기관과 서비스 정보, 정신건강에 대한 말하기, 직무스트레스 줄이기, 휴직과 직장복귀에 관한 정보 (3) 상담 (4) 연구개발.

◯ 노르웨이의 일터건강지원센터: 노르웨이의 노동환경법은 일터의 노동환경을 개선하도록 사업주를 지원하기 위해 카운티별로 일터 건강지원센터를 설치하도록 규정하고 있음 (총 19개 센터). 센터의 주요 목적은 기업의 사업주나 인사담당자들이 건강증진을 위한 활동에 더 적극적으로 관여하도록 동기부여 하는 것임. -  (1) 사업주에게 정신질환을 갖고 있는 노동자들의 낙인에 관한 인식 개선을 위해 교육, (2) 정신건강과 관련된 전문적인 도움을 받을 수 있는 자원에 대한 정보 제공, (3) 노동과 정신건강에 대한사안에 대하여 센터의 정신건강 전문가가 직접 사업장에 개입하여 중재하는 등의 활동을 수행함. 일터건강지원센터는 조기에, 효과적으로 일터에 개입할 수 있는 체계적인 구조를 제공하였음. 지금까지는 주로 

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교육과 인식개선 활동이 주를 이루었으며 수천 개의 사업장이 교육과 정보제공을 받았으나 일터의 정신건강문제는 아직 충분히 주목받지 못하고 있음. 일터건강지원센터가 잠재된 힘을 발휘하기 위해서는 (1) 모든 사업주들에게 서비스가 제공될 수 있어야 하며, (2) 정신건강전문가가 배치되어야 하고, (3) 정신과의사와 같은 전문가들과 협력해야 하며,(4) 인식개선 보다는 직접 사업주들의 문제에 대해 상담하여야 한다고 평가함.  

◯ 한국의 근로자건강센터 심리상담 프로그램: 근로자건강센터는 50인 미만의 소규모 사업장들에서 일하는 노동자들의 건강관리와 작업관련성 질환 예방을 목적으로 만들어진 서비스제공 기관임. 재원은 산재보험료로부터 조성된 산재예방기금이며 대학과 비영리법인에서 위탁 운영하고 있음. 2018년 현재 전국의 산업단지를 중심으로 21개의 근로자건강센터와 21개의 근로자건강센터 분소가 운영되고 있음. 근로자건강센터의 주요 서비스영역은 (1) 뇌심혈관질환 예방, (2) 근골격계 질환, (3) 직무스트레스 관리, (4) 작업환경 개선 지원이며 이를 위해 전문의, 간호사, 운동사, 물리치료사, 상담심리사 등의 전문직종이 상주하고 있음. 모든 서비스는 무료로 제공됨. 서울에 소재한 센터의 경우, 내방하는 노동자들에게 ⌈한국형직무스트레스 측정도구⌋ 등을 이용하여 업무와 관련된 정신건강 상의 위험도를 스크리닝 하고 있음. 정신건강 상의 증상으로 어려움을 겪는 노동자는 상담심리사의 개인 상담을 받을 수 있으며, 사업장의 전체 혹은 일부 노동자들을 대상으로 집단 정신건강증진 프로그램을 진행하기도 함. 또한, 2018년 중반부터 시작된 ⌈산업재해 트라우마 지원센터 시범사업⌋은 업무상 재해를 당한 피해자와 목격자, 동료들이 겪는 정신적 외상을 조기 발견하고 증상의 진행을 예방하기 위한 목적으로 시행되고 있음. 현재 대구근로자건강센터가 시범사업을 운영하고 향후 확대할 계획임. 근로자건강센터 모델은 이전까지 규제와 감독 중심이었던 일터의 안전보건 사업에서 정보제공, 건강증진지원, 질병예방 등의 서비스를 제공함으로써 사업장 내부에서 안전보건 역량을 갖추도록 도와주고 안전보건 체계와 문화에 실질적인 변화를 지원한다는 의미가 있음. 그러나 서비스 수요에 크게 못 미치는 현재의 인력과 재정 한계 때문에 큰 규모의 전환점을 만들지는 못하고 있음.  

(3) 고용지원 및 정신건강게이트키퍼

◯ 영국의 부처 간 합동 자살예방 대책반: 영국은 노동연금부(Department for Work and Pensions) 와 보건사회복지부(Department of Health and Social Care) 간의 공조를 통해 노동과 건강 부처 간 합동대책반Jjoint Work and Health Unit) 을 운영하고 있음. 이곳에서는 정신건강상의 문제를 갖고 있는 노동자가 직장생활을 잘 유지하도록 돕는 한편, 구직자가 새롭게 노동시장에 진입할 수 있도록 지원하고 있음. 부처 간 합동 대책을 통해 국가건강서비스(National Health Service, NHS) 내에서 정신건강 증상에 대해 제공되는 상담치료 (Talking Therapy)에 고용상담사 (employment advisor)가 결합하여 피상담자의 직업유지, 

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직장복귀, 구직 등의 과정을 지원함. 이는 정신건강상의 증상을 갖고 있는 사람이 지속적인 실직상태에 놓여 자살위험에 노출되는 상황을 방지하고, 업무관련 스트레스로 인한 정신적 불건강을 예방하는 역할을 함. 장기간의 장애나 질병으로 인해 실직수당을 신청하는 노동자는 직업능력평가(Work Capability Assessment, WCA)를 받게 된다. 이 때 노동연금부가 평가 시 사용되는 지침을 검토하여 업무에 의해 촉발되는 자살이나 자해의 위험이 사전에 정확히 감지될 수 있도록 지원함(Department of Health and Social Care 2017). 

◯ 호주의 실직자 자료 도구 Unemployment profiling tool: 정신질환을 갖고 있다는 사실은 구직자의재취업에 걸림돌이 될 수 있음. 구직지원 서비스에서 구직자의 정신건강상태를 파악하여 적절한 중재를 한다면 구직자가 재취업의 장애물로 인해 장기 실업상태로 빠지는 것을 방지할 수 있음. 호주의 구직자분류도구 (Job Seeker Classification Instrument, JSCI) 는 구직자가 갖고 있는 고용시장에서의 취약성을 발견하는 도구로서, 여기에서 발견된 정신건강 상의 문제에 대해 더 전문적인 평가를 받도록 의뢰하는 프로그램. JSCI는 소득지원 신청을 하는 구직자와 면접 혹은 전화 인터뷰를 한 후 고용시장에서 취약점으로 작용할 수 있는 정신건강 상의 문제(진단받은 질환인지 여부와 상관없이)를 발견하여 이들에게 맞는 취업지원 서비스를 제공하는 도구임. JSCI 인터뷰 중 정신건강과 관련된 문항들은 구직자가 응답을 회피하는 경우 정신건강 상의 문제를 찾아내기 어려우며, 경도 혹은 중등도의 정신질환을 민감하게 발견하지 못하는 한계를 갖고 있기 때문에 개선이 필요한 것으로 평가됨.

(4) 직업별 자살통계 생산

◯ 영국의 통계청 직종별 자살 보고서: 영국은 2012년 국가자살예방전략 (National Suicide Prevention Strategy)을 수립하여 자살률을 2021년까지 10%까지 줄이고, 2017년까지 모든 지역에 자살예방을 위한 다기관 협력 체제를 구축한다는 목표를 세운 바 있음(Department of Health and Social Care 2017). 이 전략의 일환으로 자살률이 높은 직종을 지역별, 시기별로 선별하여 각각의 특성에 맞는 자살예방 전략을 수립하고 있음. 통계청 (Office for National Statistics, ONS)은 자살위험이 높은 직종의 자살 추이를 모니터링 하여 정기적으로 별도의 보고서로 출판하고 있음. 이를 통해 자살위험 직종의 시간적 변화양상을 추적하여 시의 적절하게 중재전략을 수립하고 갱신할 수 있는 기반자료를 제공함. 이 보고서는 직종을 세분류 단위까지 구분함으로써 대분류에서 한 군에 포함될 수밖에 없는 이질적인 직종을 구분하여 자살위험이 높은 직종 군에 보다 세밀하게 접근할 수 있어 개입의 실효성을 증가시킬 수 있다는 장점이 있음. 가령, 저기술 단순노무직군 (low- skilled elementary workers) 의 경우 농업의 단순노무직, 건설업 단순노무직, 가공업 단순노무직 등을 구분하여 자살률 추이를 모니터링 함.     

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바. 노동 분야와 관련된 자살에 대한 소결

◯ 자신의 생명을 거두는 결정은 개인의 선택에 의한 것일 수만은 없으며 사회적, 경제적, 물리적, 문화적, 개인적 요인들이 복잡하게 작용하여 나타나는 현상이다. 일터는 이 요소들을 결정하는 삶의 크고 중요한 부분임. 일터의 노동환경은 노동자의 정신건강과 자살률의 변화와 밀접하게 관련되어 있음. 해고, 불안정한 고용형태, 장시간 노동, 직무스트레스, 괴롭힘을 비롯한 다양한 형태의 인권침해는 노동자의 정신건강을 악화시키고 자살위험도를 높임.  

◯ 근거에 기반을 둔 자살예방 프로그램은 노동환경을 비롯한 다양한 요인들이 복합적으로 작용하여 자살에 이르게 되는 경로들을 포괄적으로 인식하여야야 함. 둘째로 자살률과 자살과 관련된 요인들의 직종별, 지역별 분포와 시간적 변이를 시의적절 하게 추적하여야 함. 셋째로, 중재의 대상, 요인, 내용, 인력, 시기를 포함하는 장기 그리고 단기 중재 전략을 만들어야 함. 마지막으로 중재전략을 실행 프로그램으로 구체화하고 실효성을 모니터링 할 수 있는 평가체계를 갖추어야 함.

4. 자살예방의 다층적 접근의 사례들의 시사

◯ 자살예방에서 간과되어서는 안되는 것은 먼저 전체적 양상과 구조를 파악한 후 중단기적으로 집중할 영역과 장기적으로 접근할 영역을 구분하여 계획을 세우는 것임. 이와 반대로 일부 영역에서 최대의 효과를 거두는 것으로는, 즉 병소를 찾아내어 치유에 이르는 의료적 접근 방식으로는 단기적인 효과에 그칠 것이 자명함. 자살은 사회 전반에 퍼져있는 자살의 징후들을 상대해야 하며, 자살과 연결되어있는 여러 궤도들의 방향을 바꾸어야 할 것임. 대체로 이러한 조치의 상당한 부분은 보건복지(부)의 시야를 넘어서는 것으로 국무조정실의 역할은 주목이 됨. 

◯ 앞서도 살펴보았지만 사회 노동 등 보건복지 분야가 아닌 영역에서의 자살에 대한 대책은 두 정책을 융합한다거나 자살에 대한 서비스를 별도로 제공하는 방식이 아니라, 대개 이들 영역이 정신 심리적 문제에 긍정적으로 대응하도록 하거나, 해당 영역의 인력들이 서비스를 제공하면서 정서적으로 움직이게 하고, 정신문제에 대한 지각할 수 있는 대처 능력을 키우는 방식임. 예를 들어 한국 사회에서 다중 채무가 정신적으로 취약해지는 계기라면, 채무 혹은 정신이라는 전문성으로 분리시키지 않고, 바로 그 순간 그들의 문제를 보다 귀기울이고, 좀더 인격적으로 대할 수 있는 환경을 만드는 등의 개입이 대개는 낮은 전문성만으로도 이루어지는 것이 필요함. 

◯ 앞서 서술한 보건복지, 사회, 노동의 영역들은 한국사회에서 취약성이 강할 것으로 예상되나 현재는 그 상황에 대한 파악조차 되고 있지 않음. 이에 반해 해외의 몇몇 사례는 앞서 서술한 영역들과 자살과의 연관성을 인지하고, 관련 연구를 진행하고 정책에 활용하고 있

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음<표 15>. 다양한 영역을 포괄하는 자살 대책을 수립하기 위해서는 자살에 관한 이해의 범위가 충분히 넓어야 하며, 자살 문제의 전체적 특성, 문제의 규모 등에 대한 종합적인 판단이 필요하며, 이를 뒷받침하는 지표와 데이터가 필요함.

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표 . 자살 예방 정책의 확대를 위한 연관 선행지표 및 활용 예시

분야	선행지표	해외 선행연구	활용 예시
보건복지	일반질환 - Global Burden of Disease 질환분류 - Charlson Comorbidity Index - Elixhuaser Comorbidity Index	- Cattel & Jolley, 1995 - Juurlink et al, 2004 - Webb et al, 2012 - Roberts et al, 2018 - Fegg et al, 2016	- 문지기(gatekeepr) 교육 및 활용전략:  스위스 Zug 주의 2010- 2015 자살예방전략, European Alliance Against Depression의 우울 및 자살 예방 프로그램
	알코올 중독 - AUDIT - 고위험음주	- Xuan et al, 2016,  - Akechi et al, 2006 - Nakaya et al, 2007 - Holmgren & Jones, 2010 - Radvodovsky, 2009 - Babor et al, 2010 - Callaghan et al, 2013 - Giesbrecht et al, 2014	- 호주의 National Preventive Health Strategy - 음주 정책: 음주 과세, 음주 연령 제한법 도입, 알코올 판매점의 밀도(outlet density) 제한, 알코올 장애관련 치료 제공 등
사회	다중채무	- Kameyama, 2011	- 영국의 지역자살예방계획 수립 지침서: homeless services to provide, promote financial and debt counselling 등 제시 - 일본의 자살대책지원센터 라이프링크
	사회적 관계망	- Kawachi et al, 2004 - Chan et al, 2015 - Moore & Kawachi, 2017 - Poortinga, 2006 - Poortinga, 2012 - Holt- Lunstad et al, 2010 - Berkes & Loss, 2013 - Ryan & Smith, 2009 - Fässberg et al, 2012	- 일본 JSSC의 기업, 가족 단위의 연결 양식의 개발하여 지역 사회 주민의 참여를 유도하고, 이들을 관계망에 연결시키기 위한 다양한 시도 - 호주 Frankston City Council의 시니어 클럽 뉴스레터 발행
	주거	- Fowler et al, 2015 - Houle & Light, 2014 - Flavin & Radcliff, 2009	- 미국 질병관기본부의 자살예방 중재 전략: 압류 및 강제퇴거의 충격 최소화를 위한 다양한 지원 프로그램 제공 - 영국의 공공주택 임대 관리 관련자 교육
노동	해고, 비정규직 노동, 과로, 인권침해	- Chan et al, 2014 - Milner et al, 2013 - Artazcoz et al, 2004 - Saloniemi et al, 2004 - Leach et al, 2017 - Nielsen et al, 2015	- 덴마크의 노동환경의 사회심리적위험요인 평가 및 모니터링 프로그램 - 일본의 직무 스트레스 검사제도 - 영국의 건설노동자를 위한 마음의 동반자 (Mates in Mind) 프로그램 - 노르웨이의 일터건강지원센터 - 영국의 부처 간 합동 자살예방 대책반 - 호주의 실직자 자료 도구 Unemployment profiling tool

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제 4절 자살 연관통계와 관련 데이터의 활용

◯ 제4절에서는 1) 지역 자살 예방을 위한 지역관련 연관통계의 활용, 2) 한국의 기존 데이터들에서 조사되고 있는 자살 연관 통계들을 확인하고, 3) 데이터 링키지에 대한 소개와 적용을 통해 자살 연관 통계의 활용을 확대할 수 있는 방안을 모색해보고자 함. 

1. 효과적인 지역 자살예방을 위한 지역관련 데이터의 활용

◯ 일본의 JSSC는 효과적인 지역별 자살대책계획 제언을 위해 자살관련 특이사항을 파악 및 분석할 수 있는 도구(actual local suicide conditions profile)를 구축하였고, 이를 바탕으로 모든 자치단체의 자살실태를 분석 및 파악하고, 지역 특성에 맞는 자살대책계획 수립을 지원하고 있음(JSSC, 2018). 

◯ <표 16>는 ‘actual local suicide conditions profile‘과 이에 근거하여 선정된 우선순위 패키지의 예시를 보여줌(JSSC, 2018). 이는 지역의 자살 수단, 원인 등과 관련된 특성을 파악하여 맞춤형 자살예방정책 수립에 활용됨. 예를 들어 아래 표에서 자살의 경로 분석에서 unemployment→ poverty→ depression→ suicide이 가장 주된다고 하면 이 경우 우울증 뿐 아니라 실업과 가난에 대해서도 우선순위 패키지를 이용하여 접근할 수 있음. 또한 자살 수단, 원인 등의 파악은 JSSC의 자살실태·통계분석실이 담당하며, 이 기관은 여러 데이터(예: 후생노동성 자살통계, National Census, Vital statistics, corporate and economic statistics, Comprehensive Survey of Living Conditions, Survey on Time Use and Leisure Activities 등)를 사용하여 지역 간 비교가 가능한 지역별 자살현황을 제시함. 

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◯ 일본의 사례와 비슷하게 우리나라에서 지역별 자살실태를 파악하고 운선순위 패키지를 설정하기 위해서는 기본적으로 지역단위의 자료 분석을 진행할 필요가 있음. 효과적인 지역단위의 자살 원인 규명 및 예방정책 수립을 위해서는 자살 사망자 관련 정보는 물론, 시군구 및 읍면동 단위의 분석이 필요할 것으로 예상됨. 

◯ 우선 자살 사망을 확인할 수 있는 자료로는 사망원인자료, 경찰청변사자료 및 국민건강보험공단 표본코호트 자료가 있음. 사망원인자료를 통해 사망자의 자살사건 특성, 인구학적 특성, 사회경제적 특성 그리고 보건 및 건강특성에 대해 파악할 수 있음. 경찰청 변사 자료를 활용할 경우 이에 추가적으로 사회적관계망 특성 및 자살원인에 대한 확인이 가능하고, 

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국민건강보험공단 자료는 사망자 및 생존자의 인구학적 특성, 사회경제적 특성 그리고 보건 및 건강특성에 대한 정보를 담고 있음. 이러한 지역 데이터의 활용은 경찰청 변사 자료가 지니는 여러 한계들을 보완할 수 있음.

◯ 경찰청변사자료 자료는 자살자들만으로 구성되어 비교 대상이 없으며, 자살에서 한 가지 원인만을 취하고 있어 실재적 상황을 반영하기 어려운 제한점을 가지고 있으므로, 우리나라에서 지역의 자살과 관련된 현황을 파악할 수 있는 대표적인 데이터로인 지역사회건강조사와 통계청관련통계를 추가적으로 활용하여 종합적인 지역 단위의 자살예방 정책 수립을 위해 노력할 필요가 있음<표 17>. 

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2. 자살 연관통계 산출에 활용할 수 있는 국내의 기존 데이터

◯ 현재 우리나라는 다양한 영역에서의 단면조사 및 패널조사를 진행하고 있으며, 자살 연관 통계의 산출에 이러한 기존 통계가 기여할 수 있음. 국내에서 진행되고 있는 여러 단면조사 및 패널조사는 구체적으로 자살 사망을 기록하고 있지는 않다는 점에서 한계가 분명하지만, 자살 생각, 계획, 시도 등에 대한 조사를 진행하고 있음<표 18>. 또한 이러한 조사들은 보건, 사회, 복지 등 다양한 영역에 관한 기록을 하고 있어 적절히 활용할 시 정책 수립에 도움이 될 수 있음. 

◯ 특히 현재 현황 파악에 어려움이 있는 학생 자살현황과 관련해서, 청소년건강행태온라인조사 및 한국아동·청소년 인권실태조사를 활용할 경우 청소년의 평균 자살 생각 및 시도 비율을 산출할 수 있음. 또한 우울감, 스트레스 인지, 주관적 행복감 등의 정신관련 내용은 물론, 사회경제적 사항, 폭력을 포함한 다양한 항목을 조사하고 있으므로 자살위험요인 분석 시 활용 가능성이 높음. 

◯ 마찬가지로 한국의료패널은 대상자의 질환 이환 및 의료이용에 대한 조사를 구체적으로 진행하고 있어 일반질환과 자살과의 연관성 파악 시 활용될 수 있음. 또한, 국민건강영양조사를 이용할 경우 음주 빈도, 1회 평균 음주량 및 AUDIT 점수를 측정할 수 있으므로 알코올 중독 관련 자살 대응 계획 수립의 기초자료로 사용이 가능함. 

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표 . 자살관련 단면조사 및 패널조사

단면조사
조사명	조사기관	조사연도	표본대상	조사항목	자살관련 변수	정신관련 변수
청소년건강행태 온라인조사	질병관리본부	2005- 2017년 (1년 주기)	중고등학교 재학생(중고등학교 각각 400개교) 약 58,000~76,000명	일반사항, 흡연, 음주, 신체활동, 식생활, 비만, 정신건강, 손상 및 안전의식, 구강건강, 개인위생, 성 행태, 아토피·천식, 약물, 인터넷 중독, 건강형평성, 폭력 등	- 자살 생각 - 자살 계획 - 자살 시도 - 자살 시도로 인한 병원 치료 경험	- 우울감 경험 - 스트레스 인지 - 주관적 행복감
한국아동·청소년 인권실태조사	한국청소년정책 연구원	2009년- 2015년 (1년 주기)	초중 고등학교 재학생 약 9,000명	일반사항, 인권 일반원칙, 시민적 권리와 자유, 폭력 및 학대, 가정환경 및 대안양육, 장애기초보건 및 복지, 교육여가 및 문화적 활동, 특별보호조치 등	- 자살 생각	- 우울 정도 - 스트레스 정도
국민건강영양조사	질병관리본부	1998- 2005년 (3년 주기), 2007- 2016년 (1년 주기)	약 11,000~14,000 가구	가구 및 가구원 일반사항, 기본정보, 교육, 경제활동, 이환, 의료이용, 건강 검진, 예방접종, 활동제한, 삶의 질, 손상, 흡연, 음주, 신체 활동, 정신 건강, 안전의식, 비만, 여성건강, 구강건강, 영양조사, 검진조사 등	- 자살 생각 - 자살 계획 - 자살 시도	- 우울감 경험 - 스트레스 인지 - 정신문제 상담 경험
지역사회건강조사	질병관리본부	2008- 2017년 (1년 주기)	만 19세 이상 성인 약 200,000명	가구 및 가구원 일반사항, 기본정보, 건강행태, 의료이용, 이환, 예방접종, 사고 및 중독, 활동제한 및 삶의 질, 보건기관 이용, 교육 및 경제활동, 여성건강, 심폐소생술, 사회물리적환경 등	- 자살 시도	- 우울감 경험
사회조사	통계청	1990년- 2018년 (부문별 2년 주기)	약 25,000 표본가구내의 13세 이상 성인	가족, 소득과 소비, 노동, 교육, 보건, 환경, 복지, 문화와 여가, 안전, 사회참여	- 자살 생각 *짝수 연도에만 조사	- 스트레스 정도
노인실태조사	보건복지부, 한국보건사회 연구원	2007- 2017년 (3년 주기)	만 65세 이상 성인 약 10,000명	가구사항, 건강상태, 건강행태, 기능상태와 간병수발, 여가활동/ 사회활동, 경제활동, 가족/지인과의 관계 및 가구형태, 부양사항, 생활환경, 노후생활과 삶의 질, 정책적 이슈관련 현황과 노인의 의식,  인지기능, 경제상태 등	- 자살 생각 - 자살 시도	- 우울증 진단
자살실태조사	보건복지부	2013년 (5년 주기)	전국 응급의료기관 방문 자살시도자 실태조사(전수): 약 1,500명, 자살에 대한 국민 인식 조사: 만 19~75세 성인 약 1,500명	응급실 내원정보, 의학적 병력정보, 자살시도 과거력, 현재 자살시도 상황 평가, 자살 평가, 자살의도검사, 정신과적 평가 및 조치, 응급진료결과, 인구학적 특성 자살에 대한 의견, 대상자 생활관련 사항, 미디어관련, 기본 인구학적 정보 등	- 자살시도 과거력 - 현재 자살시도 평가 - 자살의도검사	- 의학적 병력정보
응급의료현황통계	국립중앙의료원	2014- 2017년 (1년 주기) *국가응급진료정보망(NEDIS) 통계	전국 응급실 내원 후 접수자	환자기본정보, 질병여부, 손상기전, 의도성여부, 보험유형, 내원경로 및 수단, 응급증상 해당 여부, 진료결과, 발병일시, 내원일시, 퇴실일시, 응급실 도착 소요시간, 응급실 재실시간, 퇴원형태 등	- 손상의 의도성 여부: 자해/자살	- 의학적 병력정보
패널조사
조사명	조사기관	조사연도	표본대상	조사항목	자살관련 변수	정신관련 변수
국민건강보험공단 표본코호트	국민건강보험공단	2006- 2015년 (청구 자료)	전국민 모집단의 2%인 약 100만명	가입자 자격사항, 사회경제적 현황, 의료이용, 요양기관 등	- 사망여부 및 사망원인	- 진료기록
한국복지패널	한국보건사회 연구원	2006- 2017년 (1년 주기)	약 7,000 가구(중위소득 60% 미만 저소득층에 전체표본의 약 50% 할당)	가구 및 가구원 일반사항, 근로활동, 경제상황, 복지욕구, 사회보장 가입 및 수급현황, 생활여건 및 사회적 관계망, 생활습관, 정신건강, 복지·사회·정치문제 인식 등	- 자살 생각 - 자살 계획 - 자살 시도	- 우울척도(Center for Epidemiologic Studies Depression Scale, CES- D) - 자아존중감 - 주관적 행복감
한국의료패널	한국보건사회 연구원, 국민건강보험공단	2007- 2016년 (1년 주기)	약 8,000 가구	사회경제적 특성, 자산규모 및 생활비 지출, 의약품 구매, 노인장기요양, 인구사회경제적 특성, 경제활동 및 소득, 건강수준, 의약품 복용행태, 의료이용 및 비용, 의료비 재원, 임신 및 출산, 건강생활습관, 활동 제한, 의료접근성, 계층인지도, 민간의료보험 등	- 자살 충동	- 우울감 경험
여성가족패널	한국여성정책 연구원	2008- 2016년 (2년 주기)	만 19- 64세 여성 약 10,000명	가구 및 가구원 일반사항, 주거상태, 소득/ 소비/ 자산과 부채, 결혼관련 사항, 가사노동, 임신 및 출산경험과 자녀계획, 자녀교육 및 가족관계, 가족관련 가치관, 여성건강 등	- 자살 생각 - 자살 계획 혹은 시도	- 우울 경험 - 스트레스 인지
고령화연구 패널조사	한국고용정보원	2006- 2018년 (2년 주기)	만 45세 이상 성인 약 10,000명	가구구성, 배우자 정보, 자녀 정보, 형제자매 정보, 부모 정보, 일상생활 및 도구적 일상생활, 인지능력, 악력, 금전적 지원, 주관적 건강상태, 만성질환, 흡연, 음주, 우울, 입원 및 병원비, 경제활동 상태, 일자리 관련 정보, 은퇴 정보, 소득 및 자산 등	- 사망여부 및 사망원인	- 우울척도(Center for Epidemiologic Studies Depression Scale, CES- D)
청년패널조사	한국고용정보원	2001- 2006년 (1년 주기), 2007- 2016 (1년 주기)	2001년 기준 만 15- 29세 청년 약 10,000명, 2007년 기준 만 15- 29세 청년 약 12,000명	일반사항, 학교생활관련 사항, 진로, 아르바이트, 사교육, 근로관련 사항, 자격증, 건강과 스트레스 등	- 자살 시도 - 자살 충동 *2010년부터 3년 단위 조사	- 우울정도 - 스트레스 정도 *2010년부터 3년 단위 조사
한국청소년 패널조사	한국청소년정책 연구원	2004- 2008년 (1년 주기)	초등학교 4학년 약 3,000명 및 중학교 2학년 재학생 약 3,600명	일반사항, 직업선택 및 진로, 여가활동, 일탈, 생활영역별 시간배분 및 중요도, 자아관, 부모 인적사항 등	- 자살 생각	- 우울 여부

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3. 자살예방 연구 확대를 위한 데이터 링키지의 가능성

가. 자살 연구에서 데이터 링키지 연구 활용의 의의

◯ 데이터 링키지는 둘 혹은 그 이상의 데이터를 개인 수준에서 연결하여 새로운 데이터를 생성하는 과정을 의미함. 데이터 링키지에 대한 관심은 자살연구의 두 가지 특징과 관련이 깊음. 첫째, 자살 연구는 매우 드문 결과를 다루기 때문에 대용량의 데이터를 필요로 함. 둘째, 자살은 사회적 현상이며, 따라서 그 설명은 사회 경제적 요인을 포함하는 거시적 접근이 필요함. 구체적으로 이와 관련된 데이터 링키지의 의의는 아래와 같음:

◯ 첫째, 연구는 연구를 뒷받침하는 이론과 가설 및 잘 짜인 설계도 중요하지만 이의 기반이 되는 데이터에 따라 질이 크게 좌우됨. 측정된 데이터의 정확성, 데이터의 규모, 데이터가 추적되는 기간의 길이 등에 따라 연구의 신뢰성과 질은 크게 영향을 받음. 자살과 같이 빈도가 드문 결과인 경우 신뢰성 있는 데이터를 구축하기 어려우며, 코호트 연구인 경우 결과가 되는 자살의 건수가 작거나, 변수를 완료된 자살(completed suicide) 대신 자살 생각(suicidal ideation) 등으로 대치하게 됨. 일종의 환자- 대조군 연구인 심리적 부검 연구는 정보의 수집 과정(정보편견, 회상편견이 작용)과 대조군 설정의 문제가 제기됨. 이런 이유로 자살 연구에서 사망원인자료와 같은 행정자료를 이용하는 것은 흔함. 사망자료 단독으로는 발생 추이 등의 기본적인 정보의 제공에 머무르게 되므로, 다른 데이터와 연결되어야 하므로 자살 연구는 사망원인자료와 다른 통계 원과의 데이터 링키지에 크게 의존하게 됨. 또한 사망원인자료와 페널, 코호트, 서베이(예, 국민건강영양조사)와 같은 기존의 이차자료와의 연계 또한 활발함. 충분한 규모의 데이터를 확보하기 위해 기존 데이터들 간의 연계를 활용할 것을 주문하는 것도 자살연구의 특수성에 대한 이해에서 비롯됨. 

◯ 둘째, 데이터 링키지 연구는 사망원인 자료(death registry)와 어떠한 자료를 연결하는지에 따라, 자살 양상의 다양한 측면을 밝혀줌. 예를 들어 “Criminality and suicide: a longitudinal Swedish cohort study”라는 스웨덴의 한 연구는 1969/70년에 징병검사를 받은 코호트 데이터(conscription)를 구축한 후(n=48834 men), (Stenbacka et al, 2014), 그 이후 35년간의 이들의 사망과 병원이용 자료, 그리고 범죄 자료를 연결하여 범죄 종류와 자살 가능성에 대해 분석하고 있음. 우리나라의 경우도 자살예방 대책 29개 세부과제의 하나로 ‘특수영역(군, 교정기관) 자살 예방 활동 강화’를 포함하고 있으나, 이를 뒷받침하기 위해 이들 인구집단에서는 어떠한 자살 유형과 경로를 밟는지에 관한 연구는 공백에 가까우며, 사정이 이러할 때 예방적 개입은 의례적인 위험 수단으로부터의 격리와 형식적인 캠페인에 머무르기 쉬움. 이에 비해 위에서 예를 든 스웨덴과 같이 범죄자들의 자살과 이 과정에 작용한 힘들에 대한 분석은 자연스럽게 사회적 중재가 어떻게 작동할 것인지에 대한 정책적 연결로 이어지게 될 것임. 이러한 연구들이 하나하나 모여 단단한 사실이 되는 과정에서 사회적 동의가 이뤄지고, 역량이 축적되고 사회적 해결로 나아갈 수 있을 것임. 특히 

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자살과 같이 사회적 원인이 크게 작용하는 사건에서 다양한 사회적 측면을 데이터로 자살과 연결하려는 데이터 링키지 연구 방법은 자살예방 연구에 잘 부합된다고 할 수 있음. 아래는 스웨덴의 데이터 링키지 연구에 활용되는 자료원으로 자살과 같이 한 문제에 집중된 데이터를 생성하는 것이 효율적이지 않은 상황에서는, 데이터 링키지는 문제의 전체적인 양상을 파악할 수 있는 최선의 방안이라고 할 수 있음<그림 16>. 

나. 데이터 링키지의 장점과 제한점

◯ 장점: 

 하나의 데이터를 넘어서는 다양한 주제(range of topics)의 연결이 가능함. 사망 결과를 포함하는 의료 혹은 보건관련 데이터 뿐 아니라 다양한 자료원과의 연결을 통해 자살 연구의 질문 범위를 넓힐 수 있음.

 데이터가 전향적, 지속적으로 이루어지므로 데이터 수집이 효율적이며, 장기간에 걸친 사건의 분석에 적절하며, 자살사건의 발생 이전에 데이터의 수집이 이루어지므로 회상편견이 없음. 

 행정자료는 국민 전체를 대상으로 데이터를 수집하기 때문에 드문 사건의 분석에 적합함. 

 데이터 링키지는 규모와 원인을 밝히는데 탁월한 연구 설계일 수 있음. 왜냐하면 이 데이터는 보통 인구집단 전체를 포함하고 있어 외부타당성(external validity)의 문제가 발생하지 

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않기 때문임(Huisman et al, 2013).

 그 밖에 비용이 절감되며, 데이터 수집에 소요되는 시간을 단축할 수 있음. 

◯ 제한점:

 정보보호의 문제가 발생할 수 있어 정보보호와 공공정보 활용사이의 균형을 찾는 것이 중요함.

 데이터의 정확성이 낮을 수 있음. 이는 코딩 시스템 혹은 코딩 관행에 의해 비롯될 수도 있으며, 데이터가 작성되는 양식 혹은 일관성의 문제로 발생할 가능성이 있음. 

 등록 데이터가 일부의 인구집단에 제한되는 경우 대표성의 문제가 제기될 수 있으나 이는 모든 데이터에 해당하는 문제임. 

다. 국내 조사를 이용한 자살에 대한 데이터 링키지의 가능성

◯ 현재 국내에는 자살 관련 변수가 포함된 여러 단면조사 및 패널조사가 진행되고 있음<표 18>. 이러한 데이터는 보건, 사회, 복지 등 다양한 영역에 관한 조사를 진행하고 있어 적절히 활용할 시 자살예방 연구 및 이에 근거한 정책 수립에 도움이 될 수 있음.

◯ 현재 국내에서 수집/운영되고 있는 단면조사 및 패널조사는 10개 이상이며, 지속적으로 증가하고 있음. 특히 패널조사가 운영되고 있는 분야는 교육, 노동, 복지, 가족, 의료등의 사회 등 다양하며 한국청소년 패널조사, 한국고령화패널조사와 같이 인생의 일정한 시기를 점하는 특수집단에 대한 조사를 포함함. 

◯ 데이터 사이의 데이터 연계(data harmonization)는 독자적 표본설계에서 비롯되는 새로운 데이터의 대표성, 데이터의 변수 간의 일치 여부 등의 문제가 발생함. 또한 데이터 구축의 시기와 패널조사의 경우 추적 기간의 차이, 인구 구성의 차이 등의 제한은 데이터 연계의 범위를 좁힐 수 있음. 이러한 자료의 고유성은 데이터 간의 연계가 데이터 재구축에 준하는 기술적 과정을 필요로 할 수 있다는 것을 의미함. 물론 규모가 큰 코호트(예, 국민건강보험공단 맞춤형 자료)의 경우 다른 데이터와 연계 없이 사망원인 데이터와의 연계만으로 자살연구 데이터로서 역할을 할 수 있을 것으로 예상됨.

◯ 보다 용이하게는 하나의 데이터에 통계청 사망원인 자료를 연결하는 데이터 링키지 방법임. 특히 각각의 자료가 교육, 노동, 복지, 청소년, 여성, 고령자와 같이 다른 집단과 영역의 특성을 담고 있어, 한국인 자살의 특성을 규명하는 다양한 의미를 밝힐 수 있음. 이 방법은 데이터 연계를 통해 자살 사건의 수가 늘어나지 않으므로 장기간 혹은 표본 크기가 충분히 커야 가능할 것으로 예상됨. 예를 들어 고령화연구패널조사 초기 3주기 동안(2006- 2010)의 자살 사례는 7건으로 자살 연구에 이용하기에는 수가 적음. 당장은 자살 보다는 자살생각과 같은 간접적 지표를 추가하거나, 기존 조사의 한 주기에 정신질환을 부가적으로 시행해 볼 수 있음. 

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◯ 하지만 국민건강영양조사와 국민건강보험공단 표본코호트는 연계키(주민등록번호) 파악이 가능한 반면, 대부분의 패널조사에서는 주민등록번호 수집이 되지 않고 생년월일, 성별 및 주소지 등의 정보만을 기록되는 제한점이 있음. 따라서 정확한 연계 가능성이 높은 자료를 위주로 데이터 링키지 가능성을 고려해볼 필요가 있음. 

라. 데이터 링키지 연구 활용 예시

(1) 국내 데이터에서 데이터 링키지의 적용

◯ 이 연구는 우리나라에서의 일반질환과 자살과의 연관성을 탐구하기 위해 국민건강보험 맞춤형자료를 이용하여 통계분석을 진행함. 국민건강보험 자료는 신체질환 및 사망원인에 대한 변수를 포함하고 있어 일반질환과 관련된 연구 가능성을 제시하고 있음. 특히 국민건강보험 데이터는 건강보험 가입자는 물론 의료급여 수급자를 포함한 전 국민의 의료이용, 상병, 급여 내역을 포함하고 있으며, 가입자 구분, 보험료 분위 수 등을 바탕으로 경제활동상태, 소득상태, 실업 여부 등을 파악할 수 있음.

◯ 통계청 사망원인 자료를 이용하여 2009- 2013년 자살사망자 75,471명을 추출한 후 국민건강보험공단 자료와 연계한 후, 상병내역을 확인한 후 사망일로부터 1년 이내 상병내역이 있는 사람 65,751명을 사례군으로 정의함. 대조군은 선행연구(Jurrlink et al, 2004)를 근거로 성과 연령을 바탕으로 1:4 매칭을 진행한 263,004명으로 지정함. 

◯ 결과변수는 자살 사망(International Classification of Diseases, ICD- 10 X60- 84)으로 정의함. 

◯ 독립변수는 Global Burden of Disease(GBD) 연구(Murray et al, 2012)의 만성질환리스트를 바탕으로 다음과 같이 분류된 신체질환으로 정의함: 신생물(Neoplasm) 28개, 심혈관계(Cardiovascular and circulatory disease) 11개, 만성호흡기병(Chronic respiratory disease) 4개, 정신 및 행동장애(Mental and behavioral disorders) 10개, 당뇨/비뇨/혈액/내분비 질환(Diabetes, urogenital, blood, and endocrine disease) 15개, 신경질환(Neurological disorders) 10개, 근골격계 장애(Musculoskeletal Disorders), 간경변증(Cirrhosis of the liver) 1개, 소화계통 장애(Digestive) 10개, 만성비감염성질환(Non- communicable diseases) 3개 등 총 97개의 질환 분류

◯ 통계분석방법으로는 우선 연구대상자의 일반적 특성을 비교하기 위해 카이제곱검정, T- test 및 분산 분석(Analysis of Variance, ANOVA)을 진행함. 단일질환의 사망위험도는 조건부 로지스틱 회귀분석을 통해 산출하였으며, 모든 통계분석은 SAS version 9.4를 이용함.

◯ 연구 대상자의 일반적 특성을 살펴보면, 성별 분포는 남성 65%, 여성 35%로 남성이 여성에 비해 약 1.8배 더 많음. 연령의 경우 전체 대상자 중 19%가 30세 미만, 57.5%가 30세 이상 65세 미만, 그리고 23.4%가 65세 이상으로 확인됨. Global Burden of Disease(GBD) 만성질환 리스트에 따른 분류지표 질환에 해당하는 비율은 자살사망자(사례군) 89.6%, 생존자(대

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조군) 70.8%이며, 자살사망자의 경우 3개 이상의 복합만성질환을 가지고 있는 경우가 60.3%임. 이는 생존자인 28.5%보다 약 2배 이상 많은 수치로, 자살사망자(사례군)가 생존자(대조군)보다 복합만성질환에 더 많이 노출됨을 보여줌<표 19>. 

표 . 연구대상자의 일반적 특성

	Number (%)				P- value*
	Suicides (N=65,751)		Survivors (N=263,004)
Gender
Men	42,865	(65.2)	171,460	(65.2)
Women	22,886	(34.8)	91,544	(34.8)
Age
< 20	3,972	(6.0)	15,888	(6.0)
20- 29	8,581	(13.1)	34,324	(13.1)
30- 64	37,815	(57.5)	151,260	(57.5)
≥ 65	15,383	(23.4)	61,532	(23.4)
Socioeconomic position					< 0.0001
High	31,887	(48.5)	129,820	(49.4)
Low	33,864	(51.5)	133,184	(50.6)
Diseases status					< 0.0001
Non specific disease	6,844	(10.4)	76,861	(29.2)
Specific disease	58,907	(89.6)	186,143	(70.8)
Number of specific disease
1	9,994	(15.2)	69,510	(26.4)
2	9,300	(14.1)	41,878	(15.9)
≥ 3	39,613	(60.3)	74,755	(28.4)

*^{p- value < 0.05}

◯ 다음으로 대분류 단일질환의 회귀분석 결과는 <표 20>에 제시됨. 대분류에 해당하는 10개 질병 군이 자살과 통계적으로 유의한 연관성을 보이는 것으로 확인됨. 특히 심혈관계(Cardiovascular and circulatory disease) [Odds Ratio (OR) 2.91, 95% Confidence Interval (95%CI) 2.85- 2.96] 및 당뇨/비뇨/혈액/내분비 질환(Diabetes, urogenital, blood, and endocrine disease) (OR 2.23, 95%CI 2.45- 2.54) 군에서 자살 가능성이 상승함. 중분류 단일질환의 회귀분석 결과는 [부록 2]에 제시됨.

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*OR: Odds ratio, 95% CI: 95 percent confidence interval

◯ 신경계통(Neurological disorders) 중분류에 해당하는 10개의 모든 질병 군이 자살과 통계적으로 유의한 연관성을 보이는 것으로 확인되며 기타 추체외로 증상(Other extrapyramidal) (OR 2.64, 95%CI 2.53- 2.76), 기타 탈수초(Other demyelination) (OR 2.27, 95%CI 1.76- 2.92), 계통성 위축(Systemic atrophies) (OR 2.26 95%CI 1.94- 2.64) 등 순으로 자살 사망위험도가 높게 산출됨<그림 17>. 

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표 . 대분류 단일질환과 자살과의 관계

	Number (%)				Likelihood of suicide
	Suicides (N=65,751)		Survivors (N=263,004)		OR* (95% CI)
Disease
Neoplasms	7,188	(10.9)	22,752	(8.7)	1.26	(1.23- 1.29)
Cardiovascular and circulatory disease	27,659	(42.1)	56,192	(21.4)	2.91	(2.85- 2.96)
Chronic respiratory disease	16,467	(25.0)	42,378	(16.1)	1.61	(1.58- 1.61)
Mental and behavioral disorders	29,284	(44.5)	28,587	(10.9)	4.16	(4.09- 4.23)
Diabetes, urogenital, blood, and endocrine disease	29,559	(45.0)	61,699	(23.5)	2.49	(2.45- 2.54)
Neurological disorders	16,202	(24.6)	29,560	(11.2)	2.23	(2.19- 2.28)
Musculoskeletal disorders	30,843	(46.9)	75,046	(28.5)	2.04	(2.01- 2.07)
Cirrhosis of the liver	15,509	(23.6)	30,629	(11.7)	1.96	(1.93- 2.00)
Digestive disease	48,552	(73.8)	141,936	(54.0)	2.14	(2.10- 2.18)
Other non- communicable diseases	9,913	(15.1)	21,898	(8.3)	1.72	(1.69- 1.76)

◯ 기존 국내의 데이터에서 질환과 자살의 연관성에 대한 연구는 단면조사인 국민건강영양조사 데이터를 이용하여 주되게는 자살생각을 위주로 전개됨. 제한된 질환을 대상으로 그것도 자살생각에 대한 위험도의 산출은 당연히 결과에 대한 신뢰성에 큰 한계로 작용함. 그에 반해 본 연구는 데이터 링키지를 통해서 질환의 종류에 제한 없이 자살에 대한 상대적 위험도를 산출할 수 있었음. 이 데이터는 질환의 종류와 자살의 연관성에 대한 것 뿐 아니라 질환별 의료이용과 자살, 질환의 이환과 사회경제적 요인의 강화효과 등에 대한 신뢰할 만한 결과를 제공할 수 있어, 데이터 링키지 연구의 의의를 잘 보여줌. 유사한 방법으로 노동관련, 금융관련, 거주 관련한 데이터들과 사망원인 데이터의 링키지가 가능하다면 자살의 실체적 모습을 보다 정확하게 반영할 수 있음.

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제 5절 자살 연관통계의 역할과 정책의 연계에 대한 제안 

◯ 기존 국내 자살 연구와 정책은 정신보건적 측면의 고위험군에 집중되는 경향이 두드러짐. 이 연구에서는 자살 예방 정책의 확대를 위한 자살연관통계의 영역을 제시하고 이들 영역에서 이루어지고 있는 해외 자살예방 정책 사례를 소개하였음. 그 사례들은 자살예방 정책이 보건, 복지, 의료, 교육, 노동, 경제 등의 다양한 영역이 유기적으로 연계되어야 함. 예를 들어 실업과 같은 노동의 영역에서 채무와 같은 금융의 영역에서 취약한 상태에 놓일 수 있다면 이에 대한 사회의 대응 방식이 달라지고, 심리적 개입이 바로 이 지점에서 이루어져야 함을 강조하였음. 이러한 취약성이 강화되는 일시적 혹은 연속적 계기들은 삶의 전과정에 따라 분포되며, 정신보건과 사회적 개입을 그 과정상에 놓는 것으로 변해야 할 것임. 

◯ 한국의 자살예방 정책은 유가족, 자살 시도자 등에 대한 대책과 같이 특정 부분에 집중됨. 이러한 영역이 자살의 우선순위가 높은 대책임에는 분명하나 이들 위험요인은 단독으로 발생하지 않으며, 고위험성마저도 다른 위험요인의 긍정성 여하에 따라 달라질 것임. 자살예방 정책은 단절이 아니라 연계와 연속성에 대한 것임. 보건복지, 사회, 노동 등 삶이 이어지는 과정들을 주목해야 하며, 이 과정들에서 삶이 피폐해지고 궁지에 몰리는 것이라면, 그 연속성에 상응한 정책들이 마련되어야 함. 그런 측면에서 우리나라의 자살예방 대책은 전체적 포괄적 연속적 측면에서 미흡한 경향을 보임.

◯ “자살로 궁지에 내몰리는 사람이 안심하며 살 수 있게 하고, 자살을 막기 위해서는 정신보건적인 관점뿐만 아니라 사회・경제적인 관점을 포함한 포괄적인 대책이 중요 합니다. 또한 이러한 포괄적인 대책을 실행하기 위해서는 다양한 분야의 시책, 사람 및 조직이 밀접하게 연계될 필요가 있습니다(일본 JSSC, 2017).” 일본에서는 앞의 인용문에서 볼 수 있듯이 자살예방에서 여러 차원의 연계를 강조하고 있음. 일본에서는 자살 요인이 될 수 있는 빈곤, 다중채무, 성적소수자 등 관련분야에서도 연계를 통한 대책이 추진되고 있으며, 개별적인 시책의 연동성을 높여 누구든지 적절한 정신보건 의료복지 서비스를 받을 수 있도록 하는 것을 강조하고 있음. 연계의 차원을 아래의 <그림 18>과 같이 「개인지원 레벨」, 「지역연계 레벨」, 「사회제도레벨」로 구분하여 개별적으로 추진하면서, 동시에 이를 종합적으로 추진하고 있음.

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◯ 자살은 한국사회의 부정적 모습을 보여주는 동시에 심각한 자기 부정이며, 수많은 사람들이 부끄러움을 때로는 행동을 토로해온 것임. 그러한 열변에 비해 우리는 아직도 자살을 해결하기 위해 차분하게 대응하였다고 주장하기에는 모르는 것이 많으며, 문제를 전체적으로 알지 못할 때 정책적 선택지는 좁아짐. 현재까지 우리가 다루어온 자살에 대한 현상보다 실재는 더 대규모 이며, 따라서 접근도 보건복지를 넘어 노동, 경제, 주거, 교육 등 사회전체에 걸쳐 있음. 우리는 이제 자살 통계와 연계된 건강보험데이터를 통해 자살의 실상을 더 잘 이해할 수 있게 되었음. 마찬가지로 데이터 링키지와 같은 방법을 통해 여러 영역의 자살과의 연관성이 데이터와 통계로서 드러나야 하며, 그렇지 않으면 자살예방대책은 보건과 의료로 협소하게 편향되거나 산발적일 수 있음.

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 대한민국 정부 관계부처 합동. 자살예방 국가 행동계획. 2018.

 문송면 원진노동자 산재사망 30주기 추모조직위원회. 산업재해 피해자 증언대회및 노동안전보건과제 대토론회. 문송면 원진노동자 산재사망 30주기 추모조직위원회 2018.

 박아름, 전종설. 알코올 중독자의 대인관계와 자살생각 간의 관계- 우울의 매개효과를 중심으로. 보건사회연구원 2014;34(1):379- 407.

 보건복지부, 중앙자살예방센터. 2018 자살예방백서. 중앙자살예방센터 2018.

 보건복지부, 질병관리본부. 국민건강영양조사 원시자료 이용지침서: 제 7기 1차년도(2016). 2018.

 보건복지부, 한국보건사회연구원. 2017년도 노인실태조사 조사매뉴얼. 2017.

 서유진. 직장괴롭힘의 피해 실태: 건강과 정서. 한국직업능력개발원 2018.

 안전보건공단. 근로자 정신보건관리 체계조사. 안전보건공단 2018.

 알코올사업지원단. 음주폐해 감소를 위한 국가전략 2020. 2011.

 이민아, 강정한. 한국 사회 자살률의 변동과 원인. 한국인구학 2014:37(2):1–19.

 이민아, 강정한. 한국 사회 자살률의 변동과 원인. 한국인구학 2014;37(2):1–19. 

 일본 경찰청. 2016년 경찰통계연보. 2016.

 임정수 등. 국내 자살원인 실태조사 및 자살 예방체계 구축에 관한 연구. 보건복지부 2008.

 중앙응급의료센터. 2014 국가응급진료정보망(NEDIS) 통계연보 제 1호. 2015.

 중앙자살예방센터. 2016 자살예방백서. 중앙자살예방센터 2016.

 질병관리본부. 2017년 지역사회건강조사 가구조사표. 2017.

 최혜금, 이현경. 우리나라 경제활동인구의 문제음주와 우울 및 자살생각과의 관련성. 대한보건연구 2016;42(1):29- 40.

 통계청. 사망원인통계 통계정보 보고서. 통계청 2017.

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 한국고용정보원. 2018년 고령화 연구패널 이용자 가이드. 2018.

 한국보건사회연구원, 국민건강보험공단. 2016년 성인가구원용 한국의료패널조사. 2016.

 한국보건사회연구원, 서울대학교 사회복지연구소. 한국복지패널 12차년도 조사자료 사용자 지침서 2018. 2018.

 한국보건사회연구원. 의료인을 통한 자살예방체계 구축방안 연구. 2010.

 한국여성정책연구원. 여성가족패널조사 가구용 설문지. 2016.

 한국자살예방협회. 자살예방자원 및 서비스 실태 조사. 2009

 한국청소년정책연구원. 2015년 아동청소년 인권실태조사 코드북. 2015. 

 한국청소년정책연구원. 한국청소년패널조사 패널 1- 6차년도 User's Guide. 2008.

 한인영, 이은진, 김소영. 정신건강증진센터 이용자 중 자살시도 유경험자와 무경험자 비교연구. 정신보건과 사회사업 2013;41(4):201- 226.

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부록 1. 국내 및 해외 자살 연구 비교의 방법론

※문헌 고찰 방법

◯ 검색엔진으로 Pubmed를 사용하여 commentary, letter, 메타분석 및 systematic review를 제외한 2000- 2008년도 사이 게재된 영문 논문을 연구 대상으로 포함함. 

◯ 검색에 사용된 핵심어는 다음과 같음: ‘Korea(n) + suicide,’ ‘Korean(n)+suicide attempt,’ ‘Korea(n)+suicide ideation,’ ‘Korea(n)+suicidal behavior,’ ‘Korean(n) suicidality,’/ ‘Japan(ese)+suicide,’ ‘Japan(ese)+suicide attempt,’ ‘Japan(ese)+suicide ideation,’ ‘Japan(ese)+suicidal behavior,’ ‘Japan(ese)+ suicidality/ ‘Sweden(ish)+suicide,’ ‘Sweden(ish)+suicide attempt,’ ‘Sweden(ish)+suicide ideation,’ ‘Sweden(ish)+suicidal behavior,’ ‘Sweden(ish) +suicidality’

◯ 이후 선정된 모든 논문은 스웨덴의 자살 연구 센터인 National Centre for Suicide Research(NASP)에서 발표한 자살 연구 분류를 기본적으로 활용하여 일차적으로 구분 (NASP, 2014). 사용된 NASP 분류 기준은 아래와 같음<부록 표 1>:

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부록 표 1. NASP 자살 연구 분류

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부록 표 2. 연도별 자살 관련 연구 수

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부록 2. 만성질환과 자살의 연관성: 전체질환의 위험도 비교

부록 표 3. 중분류 단일질환과 자살의 연관성

	Number (%)				Risk for suicide
	Suicides (N=65,751)		Survivors (N=263,004)		OR (95% CI)
Neoplasms
Esophageal cancer	122	(0.2)	586	(0.2)	0.860	(0.72- 1.03)
Stomach cancer	1,007	(1.5)	3,413	(1.3)	1.145	(1.08- 1.22)
Liver cancer	1,112	(1.7)	4,352	(1.7)	1.018	(0.96- 1.08)
Larynx cancer	69	(0.1)	260	(0.1)	1.050	(0.83- 1.33)
Trachea, bronchus and lung cancer	846	(1.3)	4,749	(1.8)	0.745	(0.70- 0.80)
Breast cancer	199	(0.3)	494	(0.2)	1.450	(1.26- 1.67)
Cervical cancer	220	(0.3)	495	(0.2)	1.552	(1.36- 1.77)
Uterine cancer	18	(0.0)	105	(0.0)	0.730	(0.46- 1.16)
Prostate cancer	835	(1.3)	2,182	(0.8)	1.409	(1.31- 1.51)
Colon and rectum cancer	1,556	(2.4)	4,113	(1.6)	1.396	(1.33- 1.47)
Mouth cancer	1,331	(2.0)	2,388	(0.9)	1.869	(1.77- 1.98)
Nasopharynx cancer	93	(0.1)	165	(0.1)	1.813	(1.48- 2.23)
Cancer of other part of pharynx and oropharynx	80	(0.1)	218	(0.1)	1.347	(1.08- 1.68)
Gallbladder and biliary tract cancer	183	(0.3)	1,247	(0.5)	0.638	(0.55- 0.74)
Pancreatic cancer	461	(0.7)	1,945	(0.7)	0.958	(0.87- 1.05)
Malignant melanoma of skin	33	(0.1)	102	(0.0)	1.224	(0.87- 1.72)
Non- malignant melanoma skin cancer	51	(0.1)	225	(0.1)	0.926	(0.70- 1.22)
Ovarian cancer	98	(0.2)	395	(0.2)	0.994	(0.81- 1.21)
Testicular cancer	13	(0.0)	22	(0.0)	1.865	(1.08- 3.22)
Kidney and other urinary organ cancers	133	(0.2)	542	(0.2)	0.985	(0.83- 1.17)
Bladder cancer cancer	219	(0.3)	717	(0.3)	1.173	(1.03- 1.34)
Brain and nervous system cancers	128	(0.2)	663	(0.3)	0.808	(0.68- 0.96)
Thyroid cancer	231	(0.4)	528	(0.2)	1.531	(1.34- 1.74)
Hodgkin's disease	3	(0.0)	29	(0.0)	0.479	(0.16- 1.47)
Non- Hodgkin's lymphoma	79	(0.1)	468	(0.2)	0.721	(0.58- 0.90)
Multiple myeloma	49	(0.1)	238	(0.1)	0.853	(0.64- 1.13)
Leukemia	51	(0.1)	415	(0.2)	0.545	(0.41- 0.72)
Other neoplasms	2,117	(3.2)	10,393	(4.0)	0.832	(0.80- 0.87)
Cardiovascular and circulatory disease
Rheumatic heart disease	319	(0.5)	648	(0.3)	1.665	(1.49- 1.86)
Ischemic heart disease	8,258	(12.6)	16,379	(6.2)	1.901	(1.85- 1.95)
Cerebrovascular disease	7,540	(11.5)	16,701	(6.4)	1.761	(1.72- 1.81)
Hypertensive heart disease	2,531	(3.9)	5,274	(2.0)	1.692	(1.62- 1.76)
Cardiomyopathy and myocarditis	317	(0.5)	767	(0.3)	1.476	(1.32- 1.65)
Atrial fibrillation and flutter	1,325	(2.0)	4,115	(1.6)	1.232	(1.17- 1.30)
Aortic aneurysm	145	(0.2)	475	(0.2)	1.172	(1.00- 1.38)
Peripheral vascular disease	6,478	(9.9)	10,067	(3.8)	2.182	(2.12- 2.24)
Endocarditis	13	(0.0)	77	(0.0)	0.722	(0.42- 1.24)
Hypertension	21,744	(33.1)	44,069	(16.8)	2.535	(2.49- 2.59)
Other cardiovascular and circulatory disease	307	(0.5)	938	(0.4)	1.238	(1.11- 1.39)
Chronic respiratory disease
Chronic obstructive pulmonary disease	12,550	(19.1)	32,292	(12.3)	1.555	(1.52- 1.59)
Pneumoconiosis	70	(0.1)	236	(0.1)	1.145	(0.91- 1.45)
Asthma	8,201	(12.5)	20,641	(7.9)	1.527	(1.49- 1.56)
Interstitial lung disease and pulmonary sarcoidosis	319	(0.5)	897	(0.3)	1.319	(1.18- 1.47)
Mental and behavioral disorders
Schizophrenia	4,963	(7.6)	2,752	(1.1)	3.459	(3.36- 3.56)
Alcohol use disorders	3,406	(5.2)	2,260	(0.9)	3.197	(3.09- 3.31)
Drug use disorders	776	(1.2)	101	(0.0)	4.564	(4.25- 4.90)
Unipolar depressive disorders	17,731	(27.0)	11,915	(4.5)	4.018	(3.95- 4.09)
Bipolar affective disorders	3,174	(4.8)	1,882	(0.7)	3.316	(3.20- 3.44)
Anxiety disorders	17,791	(27.1)	16,459	(6.3)	3.449	(3.39- 3.51)
Eating disorders	228	(0.4)	317	(0.1)	2.117	(1.86- 2.41)
Pervasive development disorders	3	(0.0)	11	(0.0)	1.075	(0.34- 3.36)
Childhood behavioral disorders	403	(0.6)	502	(0.2)	2.274	(2.06- 2.51)
Other affective disorders	1,798	(2.7)	1,529	(0.6)	2.797	(2.67- 2.93)
Diabetes, urogenital, blood, and endocrine disease
Diabetes mellitus	13,049	(19.9)	24,961	(9.5)	2.085	(2.04- 2.13)
Acute glomerulonephritis	243	(0.4)	468	(0.2)	1.721	(1.52- 1.95)
Chronic kidney disease	1,371	(2.1)	3,056	(1.2)	1.573	(1.49- 1.66)
Urinary disease and male infertility	8,179	(12.4)	17,382	(6.6)	1.894	(1.85- 1.94)
Gynecological disease	534	(0.8)	1,576	(0.6)	1.278	(1.17- 1.39)
Hemoglobinopathies and hemolytic anemias	63	(0.1)	191	(0.1)	1.243	(0.97- 1.59)
Thyroid disorders	8,929	(13.6)	16,586	(6.3)	1.924	(1.88- 1.97)
Other endocrine	1,789	(2.7)	3,957	(1.5)	1.591	(1.52- 1.67)
Metabolic disorders	17,491	(26.6)	34,980	(13.3)	2.069	(2.03- 2.11)
Diabetic nephropathy	2,757	(4.2)	4,820	(1.8)	1.903	(1.83- 1.98)
Macular degeneration	1,311	(2.0)	2,172	(0.8)	1.931	(1.83- 2.04)
Diabetes with CVD	1,968	(3.0)	3,790	(1.4)	1.766	(1.69- 1.85)
Diabetes with other complications	2,727	(4.2)	5,714	(2.2)	1.677	(1.61- 1.75)
Diabetic foot	1,046	(1.6)	2,212	(0.8)	1.633	(1.54- 1.74)
Diabetes with no complication	10,186	(15.5)	18,985	(7.2)	2.020	(1.98- 2.07)
Neurological disorders
Alzheimer’s disease and other dementias	3,796	(5.8)	11,389	(4.3)	1.317	(1.27- 1.37)
Parkinson's disease	1,610	(2.5)	2,212	(0.8)	2.196	(2.09- 2.31)
Epilepsy	3,709	(5.6)	5,252	(2.0)	2.181	(2.11- 2.26)
Multiple sclerosis	35	(0.1)	58	(0.0)	1.891	(1.36- 2.64)
Migraine	3,224	(4.9)	4,294	(1.6)	2.237	(2.16- 2.32)
Tension- type headache	4,324	(6.6)	5,843	(2.2)	2.245	(2.18- 2.32)
Systematic atrophies	161	(0.2)	199	(0.1)	2.263	(1.94- 2.64)
Other extrapyramidal	2,173	(3.3)	2,104	(0.8)	2.643	(2.53- 2.76)
Other demyelination	60	(0.1)	74	(0.0)	2.265	(1.76- 2.92)
Polyneuropathy	3,921	(6.0)	6,955	(2.6)	1.908	(1.85- 1.97)
Musculokeletal disorders
Rheumatoid arthritis	2,201	(3.4)	3,892	(1.5)	1.861	(1.78- 1.94)
Osteoarthritis	14,151	(21.5)	28,418	(10.8)	2.046	(2.00- 2.09)
Low back and neck pain	25,868	(39.3)	58,242	(22.1)	2.010	(1.98- 2.04)
Gout	1,906	(2.9)	3,488	(1.3)	1.808	(1.73- 1.89)
Osteoporosis	5,928	(9.0)	12,250	(4.7)	1.874	(1.82- 1.93)
Cirrhosis of the liver
Cirrhosis of the liver	15,509	(23.6)	30,629	(11.7)	1.961	(1.93- 2.00)
Digestive disease
Peptic ulcer disease	18,188	(27.7)	38,093	(14.5)	1.942	(1.91- 1.98)
Gastritis and duodenitis	44,510	(67.7)	125,626	(47.8)	2.036	(2.00- 2.07)
Appendicitis	327	(0.5)	986	(0.4)	1.249	(1.12- 1.39)
Paralytic ileus and intestinal obstruction without hernia	1,225	(1.9)	3,488	(1.3)	1.314	(1.24- 1.39)
Inguinal or femoral hernia	167	(0.3)	615	(0.2)	1.071	(0.92- 1.25)
Noninfective inflammatory bowel disease	6,767	(10.3)	13,592	(5.2)	1.761	(1.72- 1.81)
Vascular disorders of intestine	103	(0.2)	352	(0.13)	1.133	(0.93- 1.38)
Gall bladder and bile duct disease	1,573	(2.4)	5,358	(2.0)	1.142	(1.09- 1.20)
Pancreatitis	3,020	(4.6)	5,108	(1.9)	1.925	(1.86- 2.00)
GERD etc.	17,316	(26.3)	35,698	(13.6)	1.923	(1.89- 1.96)
Other non- communicable diseases
Glaucoma	5,045	(7.7)	11,115	(4.2)	1.627	(1.58- 1.68)
Cataracts	5,679	(8.6)	11,115	(4.2)	1.806	(1.75- 1.86)
Other vision loss	3,324	(5.1)	6,730	(2.6)	1.710	(1.65- 1.77)

*OR=Odds ratio, 95% CI= 95 percent confidence interval

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부록 3. 호주 Frankston 지역에서 발행하는 시니어 클럽 뉴스레터

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