Suicide Statistics Research Articles

Epidemiological data suggest antidepressants reduce suicide risk among depressives

In spite of the availability of antidepressant medication for several decades, it has not been shown that such medication lowers the risk for suicide in depressed patients. This report explores this apparent paradox by means of pharmacoepidemiological methods. Data on the prevalence of depression in the population and among suicides as well as data on the prevalence of antidepressant medication in depressed suicides were obtained from a review of the literature. Data on the prevalence of antidepressant medication in the population in 1990–1991 were obtained from the statistics of the Swedish National Corporation of Pharmacies. It was found that only one in five depressed individuals with major depression were treated with antidepressants in Sweden. The calculated risk for suicide among depressed patients who were treated with antidepressants was 141 per 100 000 person years and, among the untreated, 259 per 100 000 person years (i.e., 1.8 times higher among the untreated). This supports the hypothesis that antidepressant medication decreases the risk for suicide in depressed patients. The reason this has not been obvious in the general suicide statistics seems to be that so few depressed people are treated with antidepressants. Effective suicide prevention strategies should include intensive efforts to recognize and treat more depressed people.

Studying suicide

Modern approaches to the study of suicide are preoccupied by the idea of ‘risk’ factors, but it is here argued that this approach does little to advance our understanding of suicide rates and does not in fact constitute a theory at all. It is suggested that a reassessment of the now unfashionable writings of Emile Durkheim would show that he still has much to teach us in this area. The article begins with reference to current concerns over recent suicide statistics in Britain and the US. It briefly criticizes modern approaches to an understanding of these statistics through the notion of ‘risk factors’. It provides a detailed commentary on Durkheim's study and suggests that his theory is somewhat more sophisticated and insightful than the rather crude recent attempts at understanding. However, it is recognized that both approaches retain considerable difficulties, not least in relation to their use of statistics, and reference is briefly made to the possibilities of a poststructuralist solution to these problems. Finally, the paper offers a tentative suggestion for continuing work in this area that is driven by theoretical reflection.

Collecting suicide statistics for the severely mentally ill

Since the Health of the Nation government document (Department of Health, 1992) set the target for the reduction of suicide in the severely mentally ill by 33% by the year 2000 it has become necessary to collect the suicide data for this population of patients at district and national level. There are a range of problems concerning the definition and identification of patients with severe mental illness as well as problems concerning the compilation of suicide data for this population at district level.

New worries for the Wairarapa

This week I drove with my daughters through dry, summer-hard country to the Wairarapa coast. We make the trip several times a year, and each time the creeping darkness of tens of thousands of acres of pinus radiata has encroached a little further onto the onceprosperous farmland . I was poignantly reminded of a conversation I'd just had with a friend, after she'd spent a day delivering census papers out to the coast. Census enumerators are supplied with demographic figures from five years earlier to ensure they miss no-one in these remote areas. She reckoned that the population of this particular part of rural Wairarapa had fallen by at least 30% since 1991. The farmers who have stayed hate the pine forests. Some of them now live in what amounts to forest clearings, without neighbours near at hand, going slowly mad with loneliness and claustrophobia . Pinus radiata has even changed the climate. At least one coastal farm has been experiencing winter frosts the last year or two where no frost has lain since the beginning of time. Where have all the farmers gone? I could hazard a guess, because my own farming family is seriously considering doing a runner when our lease expires in three years. The creeping contagion of the largely Japanese-owned pine forest isn't our problem. Ours is simply that, hard as we may work, fertilise, cull weak stock and try to ride the market, we can't make a buck. And we're not alone. Lately, the combination of land prices inflated by factors including the growth of forestry and a thrivingdairy industrycoupled with a strong dollar and the manic anti-inflationary mindset of the Reserve Bank (egged on by the Business Round Table) has conspired to put sheep, beef and often arable farmers into deep trouble . Let me give you some rough figures. An averagemedium hill country farm of, say, 800 acres, is still selling for $1 million plus. This farm can probably support 4000 stock units, or maybe a little more. But there's no way that the farm, unless it's freehold, can support a family without substantial off-farm income -brought in by whichever members can rustle up another marketable skill. Not so long ago the same farm would not only have kept a large family more than comfortably but it would have employed a stock manager, head shepherd, general hand and cadet into the bargain. These days, falling meat and wool prices ensure that few farmers even those whose land has been in the family for generations are anything like debtfree. The mid-eighties subsidy removal, GATT uncertainties, and, perhaps most tellingly, the cringing attitude of successive agricultural bureaucracies towards adopting an aggressive single-desk marketing strategy, have seen to that. Our meat industry is plagued by internal competition among processors all marketing their own lines to various offshore buyers, and cutting the suppliers' throats as they do. What did you pay for your last beef roast? $14 or $15 .. ? Last week's beef schedule paid the farmer $1.55 per kilo for prime beef. Cull cow has now dropped to below the dollar mark. Ask yourself where the rest goes! A normal economic farm can carry some 600 cattle beastsgrossing $90,000 per year. After fertiliser, animal health, contractor costs, and repairs and maintenance to fences, farm, plant and vehicles, you can knock out about $70,000 of that. Yep$70,000! And no, debt repayment is not included in this figure. That, and the family's living expenses, are taken from the remaining $20,000. I haven't just pulled this figure out of the air I'm indebted to Federated Farmers, who are monitoring the problem with growing alarm. No' wonder farmers are talking of walking off the land. No wonder they're selling out to the creeping blight of pinus radiatataking a quick buck to invest in a more certain future. No wonder farmers' daughters and sons are studying commerce, medicine, law, homoeopathyanything to escape the downward spiral. No wonder farmers are starting to show up in the suicide statistics. I welcome a change of Minister. One can only hope that Lockwood Smith, as Minister of Agriculture, will put his money where his mouth is and encourage the development of a forceful and coherent marketing strategy for the New Zealand meat industry. Until this happens, farmers will continue to walk out, sell to forestry, or simply succumb to despair. I'll certainlyand with great sadnessstart looking for another job. And I wonder what, five years down the track, the census figures will show?

The coroner's system and under-reporting of suicide.

This study investigates the under-reporting of suicide with particular reference to differences between sex and age groups and the various modes of suicide. The study was performed retrospectively using the files of H M Coroner for South Yorkshire (West) over the years 1985 to 1991. There were 536 deaths judged on the balance of probability to be suicidal in nature. Only 60 per cent of these deaths received a suicide verdict and would therefore register in official suicide statistics. A significantly smaller proportion of females (51.7 per cent) received a suicide verdict than males (64.5 per cent). Of the young females (< 45) 61.7 per cent were given a suicide verdict compared to 46.6 per cent of older females (45+). These differences are explained by different preferences for mode of suicide, in particular for poisoning using solids or liquids. Only 40 per cent of cases within this category received a suicide verdict. Drowning showed an even smaller percentage (24 per cent). Self-immolation (42 per cent) and jumping from a height (51 per cent) were also under-represented. Of these, self-poisoning, drowning and jumping from a height were relatively popular among females. In contrast, common causes of death favoured predominantly by males--hanging and carbon monoxide poisoning--received a high percentage of suicide verdicts (81 per cent and 90 per cent). Thus official suicide statistics produce a distorted view of the suicide population with relative under-reporting of females, particularly older females, and marked under-reporting of some causes of death, notably poisoning using solids or liquids, drowning, self-immolation and jumping from a height.

Suicide and undetermined violent deaths in Malaysia, 1966-1990: evidence for the misclassification of suicide statistics.

Suicide statistics are generally recognised to be unreliable. This study of the reported rates of suicide in West Malaysia between 1966-1990 shows that the mean crude suicide rate between 1966-1974 was 6.1 per 100,000, but had dropped drastically between 1975-1990 to a mean of 1.6 per 100,000. Three lines of evidence are presented to show that this reduction in the suicide rate is due to a systematic misclassification of medically certified suicides as deaths due to undetermined violent deaths (which refers to violent deaths not known to be accidentally or deliberately inflicted). Firstly, the large drop in reported suicide rates corresponds closely to an increase in the rate of deaths due to undetermined violent deaths. There is a highly positive negative correlation between the two rates (coefficient of correlation, r = -0.9). Secondly, the misclassification appears to be mainly a problem with the medically certified deaths which follow the ICD classification. The mean ratio of uncertified to certified suicides before 1975 was 0.8, but from 1975 onwards the mean was 3.1. This is in contrast to the corresponding ratio for deaths due to all accidents which has remained fairly constant throughout these years. Thirdly, the race and sex differences for the rates of undetermined violent deaths are identical to those of suicide. Taking the misclassification into account the corrected suicide rate for West Malaysia is estimated to be between 8-13 per 100,000 since 1982.

Recent changes in suicide rates in selected eastern European and other European countries.

Recent major political changes in Eastern European countries might have affected their suicide rates. For this article, suicide statistics available to the World Health Organization were used to compare data from eight Eastern European countries to those from seven countries in Northern or Western Europe. Comparisons were made between 1987 and 1991/92 data using total suicide rates for each country, rates by gender, and rates for the elderly (age 75 and older). The total rates indicated an increase in suicide in Eastern European countries and a decrease in other European countries. The ratio of male-to-female suicides in the Eastern European countries increased during this time as well, more than in other European countries. Among those over the age of 75, however, rates of suicide in Eastern European countries decreased; this pattern was less clear in the European countries chosen for comparison. The article discusses the role of economic, cultural, and health service factors affecting these trends.

Suicide and aging. I: Patterns of psychiatric diagnosis.

Rates of suicide differ markedly as a function of age and gender. In a great majority of countries that report suicide statistics, rates are higher in the elderly than in younger age groups. Few data are available to determine whether this age-related pattern of rates is reflected in a differential prevalence of other factors known to be associated with increased suicide risk. Using the psychological autopsy method, researchers have established the distribution of psychiatric diagnoses in samples of adolescents, young adults, and elders who have committed suicide, and in victims across the life course in community-based populations. Review of those studies reveals that affective disorders, substance use disorders, and their comorbidity are common in completed suicides of all ages. Although methodologic issues and cohort and period effects limit the conclusions that can be drawn, comparison by age within and between studies further suggests that depressive illness is more common and substance abuse less prevalent in later-life victims. That the aging process itself (biological, psychological, and social) may account for the observed pattern has important implications for further research and the design of intervention strategies. There is a need for more coordinated and comprehensive study of psychopathological correlates of suicide across the life course in a broad range of cultures.

Suicide prevention from a public health perspective.

The public health approach to health problems provides a strong framework and rationale for developing and implementing suicide prevention programs. This approach consists of health-event surveillance to describe the problem, epidemiologic analysis to identify risk factors, the design and evaluation of interventions, and the implementation of prevention programs. The application of each of these components to suicide prevention is reviewed. Suggestions for improving surveillance include encouraging the use of appropriate coding, reviewing suicide statistics at the local level, collecting more etiologically useful information, and placing greater emphasis on analysis of morbidity data. For epidemiologic analysis, greater use could be made of observational studies, and uniform definitions and measures should be developed and adopted. Efforts to develop interventions must include evaluating both the process and the outcome. Finally, community suicide prevention programs should include more than one strategy and, where appropriate, should be strongly linked with the community's mental health resources. With adequate planning, coordination, and resources, and the public health approach can help reduce the emotional and economic costs imposed on society by suicide and suicidal behavior.

Increased rates of depression: update of epidemiological findings and analytical problems

The evidence for an increased incidence of rates of depressive conditions, defined as depressed mood, depressive syndromes or depressive disorders, is reviewed. Findings from prospective studies, family genetic studies, community surveys, repeated cross-sectional surveys, admission data and suicide statistics are summarized. Methodological problems and difficulties in the analysis and interpretation of these results are then summarized. Because converging results from studies conducted with various designs, sampling and measurement strategies are convergent, it is concluded that the increase over time of depressive phenomena is a plausible finding. However, its magnitude remains unknown and is probably smaller than sometimes claimed. Furthermore, studies have failed to demonstrate that the increase in rates was specific to depressive conditions. Finally, it is noted that these epidemiological enquiries have failed to provide cues on the possible mechanisms underlying these secular changes.

Why Are the British Hanging Themselves?

Suicide statistics for Britain (England and Wales) from 1950 to 1990 are analysed. A rising suicide rate among males, particularly the young, is associated with an increased use of hanging as a suicide method. The same trend is not seen among females. Death by hanging can seldom be concealed or regarded as other than suicide, so statistics for suicidal hanging are likely accurate. Increased suicidal hangings cannot be explained by changes in the availability or awareness of the method and must reflect change in choice of method. Hanging as a suicide method has been historically unpopular in Britain because of the dishonorable repute associated with its use for judicial execution. The abolition of judicial hanging in Britain in 1965 may have led to an increased acceptability of hanging as a suicide method. The resultant increased use of this highly lethal method may be one underlying cause of the increased numbers of completed suicides and the rise in the suicide rate.

Noncompliance in the elderly: a pathway to suicide.

Current suicide statistics only represent a portion of suicides committed by the elderly. Indirect self-destructive behaviors (ISDBs) cause many more deaths than direct methods yet they often are ignored, misinterpreted, or unidentified. Medical noncompliance is identified as a form of ISDB, leading to diminished quality of life and an expedited death. While noncompliance occurs for a variety of reasons, it is a form of self-destruction for a portion of the elderly population. The nurse practitioner is in a unique role to identify ISDBs, as well as risk factors for developing these behaviors, and to construct methods for intervening and supporting those who wish to continue life.

Suicide in Alaska Natives, 1979-1984

Alaska native suicide data were reviewed for every Alaska native suicide (N = 90) from death certificate data for the years 1979-1984 and compared to suicide statistics of age- and sex-matched groups of the entire U.S. population. The yearly suicide rate for Alaska natives was about twice that for the United States. Most of this difference was accounted for by dramatically and significantly greater rates for young, single, Alaska native men compared to white men in the U.S.; this was true for both the 15-24 and 25-34 age groups. With advancing age, suicide rates among Alaska natives decreased; the rates for the 35-44 and 45-54 male groups were still much greater, but not significantly so, than the rates for the comparable U.S. groups. After age 55, no suicides were reported for Alaska natives while U.S. white men had their highest suicide rates in the 55-64 and 65 and above groups. A number of social factors appear to have fueled the rise in suicide rates in young Alaska native men, including: economic growth, industrialization and changing lifestyles; prevalence of firearms; and a high rate of alcoholism.

Australian Suicide Data and the use of “Undetermined” Death Category (1968–1985)

There has been considerable recent debate about the impact that changes in the use of the "undetermined" death classification may have upon trends in national suicide statistics. This study focused on changes over time within each state in Australia in an attempt to determine the source of apparent patterns in national data. Considerable intra- and inter-state variability was revealed, and it was concluded that, apart from a general trend for decreasing use of the undetermined category, the data are not of sufficient quantity to warrant further interpretation. The suggestion that changes in classification practices by coroners may have contributed to the rise in young male suicides was not supported.

Trends in racial differences in U.S. suicide statistics

Abstract Although suicide rates for the U.S. white population are markedly higher than those for the U. S. nonwhite population, it has been suggested that racial differences are changing as nonwhite rates increase. Official suicide figures by race for 1933 to 1985 revealed slightly reduced racial differences, but the differences were produced largely by white suicide rate decreases and not by nonwhite increases. Except in young adulthood, racial differences remain large, and these data indicate that no significant change in racial differences has occurred or seems likely in the near future.

Factors Related to Sex Differences in Suicidal Behavior among Black Youth

A review of suicidal behavior among Black youth, IS to 24 years of age, indicates significant differences between males and females in rates and patterns of attempted and completed suicide. The heuristic value of three major theories of suicide is discussed in terms of Black youth suicidal patterns. Methodological issues of the validity and reliability of suicide statistics for Black youth are also examined. Socioculturalfactors contributing to sex differences in Black youth suicide are analyzed, as well asfamily, school, peer, and community experiences that reinforce thesefactors. Young Black males appear to be more vulnerable than young Black females to suicide because of their differential exposure to multiple risk factors in all of these domains. Implications for future research on this neglected topic are discussed and proposals are offered to enable practitioners to develop more effective strategies of prevention and early intervention in order to reduce the rates of Black youth suicide.

A consideration of the validity and reliability of suicide mortality data.

The question of the validity and reliability of suicide statistics may be considered at three levels: (1) Are suicide deaths misidentified or differentially identified across jurisdictions or over time? (2) To what degree are suicide deaths misidentified? and (3) Is the degree to which suicides are misidentified sufficient to threaten the validity of research based on suicide statistics? There is general agreement that suicides are likely to be undercounted, both for structural reasons (the burden-of-proof issue, the requirement that the coroner or medical examiner suspect the possibility of suicide) and for sociocultural reasons. There is also substantial anecdotal and empirical evidence suggesting that the mode of death for some true suicides is in fact certified as other than suicide. Overall, it does not seem that very many true nonsuicides are incorrectly certified as suicides. There is not, however, much agreement as to the degree to which true suicides are undercounted. At least some of the inconsistencies in the findings of different investigators arise because the validity of suicide certification seems to vary from place to place. But the source of apparent conflicts in many of the findings is undoubtedly the lack of a "gold standard" against which the verdicts of any given death certification process can be measured. At best, we can estimate that the sensitivity with which coroners and medical examiners certify true suicides varies from approximately 55% to 99%. A central question in estimating the sensitivity of suicide certification is this: What proportion of true suicides are either equivocal or likely to go unsuspected by the coroner or medical examiner? Very little has been done to investigate this issue. Yet the sensitivity of suicide certification clearly varies for equivocal versus unequivocal suicides. As shown in Table 1.2, specificity is also at issue when it comes to certifying equivocal cases. The final question--whether the degree of undercounting of suicide deaths is so great that it threatens the validity of research based on official statistics--is at the crux of the general concern about suicide certification. There are examples of studies in which conclusions based on crude comparisons of reported suicide statistics appear to be invalid. For the most part, these are comparisons among nations with substantially differing death certification procedures. When official statistics are interpreted with a degree of caution and an understanding of the source and direction of biases likely to affect the published rates, however, it seems unlikely that major conclusions based on these statistics will be in error.(ABSTRACT TRUNCATED AT 400 WORDS)

Toxic radiation exposure and the epidemiology of violent death: confronting obstacles to productive inquiry.

As de Man (2) has noted in his thoughtful commentary on my recent paper published in this journal ( 4 ) , the task of investigating the extent to which developmentally early exposure to toxic radiation may induce a predisposition to the kinds of criminal violence that contribute to homicide and suicide statistics, will be a challenging one indeed. I-Iopefully, professional dialogue of the sort which he has initiated, will facihtate optimally effective efforts to meet chat challenge. In any event, it is in che spirit of such facilitation that I herein offer my reply to the important issues so capably raised by Dr. de Man. Professor de Man has suggested that exposure to toxic radiation may be merely a proxy variable for more fundamental processes. H e may be right. My feeling, however, is that it is st111 much too early in development of scientific understanding of the complex, organismic phenomena involved in studying criminally violent behavior, to be sure just which are proxies and which are the real ones. Correspondingly, I'm inclined to think that the fruitfulness of research along these lines might be enhanced by acknowledging the possibility that radiation exposure is a legitimate variable in its own right, interactively involved with biological and social psychological processes which may be more apparently associated with statistical measures of criminally violent behaviors. As a social scientist, my primary objective in the follow-up paper to which Dr. de Man has responded, was to stimulate interest in programmatic, multivariate analyses oriented to disentangling the relative contributions ol many potential variables, including toxic radiation exposure, to violent crime. The causal modeling method for evaluating hypotheses about latent variables as described by Bentler (2), might be particularly appropriate for these purposes. In my judgment, such an approach, using archival data bases the way I did in my preliminary study, is not incompatible with the direction for inquiry recommended by Dr. de Man. If interest in the possible influences of radiation on dimensions of behavior other than criminal violence is stimulated thereby, my more personal motives for doing this work w d also have been satisfied.

Operational Criteria for the Determination of Suicide

Suicide is an important public health problem for which we have an inadequate public health database. In the United States, decisions about whether deaths are listed as suicides on death certificates are usually made by a coroner or medical examiner. These certification decisions are frequently marked by a lack of consistency and clarity, and laws and procedures for guiding these decisions vary from state to state and even from county to county. Without explicit criteria to aid in this decision making, coroners or medical examiners may be more susceptible to pressures from families or communities not to certify specific deaths as suicide. In addition, coroners or medical examiners may certify similar deaths differently at different times. The degree to which suicides may be underreported or misclassified is unknown. This makes it impossible to estimate accurately the number of deaths by suicide, to identify risk factors, or to plan and evaluate preventive interventions. To remedy these problems, a working group representing coroners, medical examiners, statisticians, and public health agencies developed operational criteria to assist in the determination of suicide. These criteria are based on a definition of suicide as "death arising from an act inflicted upon oneself with the intent to kill oneself." The purpose of these criteria is to improve the validity and reliability of suicide statistics by: (1) promoting consistent and uniform classifications; (2) making the criteria for decision making in death certification explicit; (3) increasing the amount of information used in decision making; (4) aiding certifiers in exercising their professional judgment; and (5) establishing common standards of practice for the determination of suicide.

Suicide trends in Canada, 1956-1981.

Using official suicide statistics, this study examined suicide rates in Canada over a 25-year span (1956 to 1981) as a function of age, gender, and geographical region. The analysis revealed that, for both sexes, the risk of suicide among the 15-24 year-olds increased at a faster rate than in any other age group. Male and female age-standardized suicide rates demonstrated an overall increase between 1956 and 1981. The trend for males was one of continuous increase, whereas female rates reached a maximum in 1976 and then decreased. Regional differences in suicide rates were also apparent. Although not strictly observed, a trend toward increasing risk of suicide in males as one proceeds westward across Canada was found. For females, a pattern of increasing suicide with more westerly location was also found, except that Ontario and the Prairie Provinces were in reverse order. Several possible explanations for these findings are presented.