Chapter 2: Burden of Mental and Behavioural Disorders:
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Suicide is the result of an act deliberately initiated and performed by a person in the full knowledge or expectation of its fatal outcome. Suicide is now a major public health problem. Taken as an average for 53 countries for which complete data is available, the age-standardized suicide rate for 1996 was 15.1 per 100 000. The rate for males was 24.0 per 100 000 and for females 6.8 per 100 000. The rate of suicide is almost universally higher among men compared to women by an aggregate ratio of 3.5 to 1.
Over the past 30 years, for the 39 countries for which complete data is available for the period 1970-96, the suicide rates seem to have remained quite stable, but the current aggregate rates hide important differences regarding the sexes, age groups, geography and longer time trends.
Geographically, changes in suicide rates vary considerably. Trends in the mega-countries of the world those with a population of more than 100 million are likely to provide reliable information on suicide mortality. Information is available for seven of eleven such countries for the last 15 years. The trends range from an almost 62% increase in Mexico to a 17% decrease in China, with the United States and the Russian Federation going in opposite directions by the same 5.3%, as shown in Figure 2.4. Two remarks are needed: first, probably only the size of their populations puts these countries in the same category, as they differ virtually in every other aspect. Second, the magnitude of the change does not reflect the actual magnitude of suicide rates in those countries. In the most recent year for which data are available, suicide rates range from 3.4 per 100 000 in Mexico to 14.0 per 100 000 in China and 34.0 per 100 000 in the Russian Federation.
Figure 2.4 Changes in age-standardized suicide rates over specific time periods in countries
It is very difficult, if not impossible, to find a common explanation for this diverse variation. Socioeconomic change (in any direction) is often suggested as a factor contributing to an increase in suicide rates. However, although this has been documented on several occasions, increases in suicide rates have also been observed in periods of socioeconomic stability, while stable suicide rates have been seen during periods of major socioeconomic changes. Nevertheless, these aggregate figures may hide important differences across some population segments. For instance, a flat evolution of suicide rates may hide an increase in men's rates statistically compensated for by a decrease in women's rates (as occurred, for example, in Australia, Chile, Cuba, Japan and Spain); the same would apply to extreme age groups, such as adolescents and the elderly (for example, in New Zealand). It has been shown that an increase in unemployment rates is usually, but not always, accompanied by a decrease in suicide rates of the general population (for example, in Finland), but by an increase in suicide rates of elderly and retired people (for example, in Switzerland).
Alcohol consumption (for example, in the Baltic States and the Russian Federation) and easy access to some toxic substances (for example, in China, India and Sri Lanka) and to firearms (for example, in El Salvador and the United States) seem to be positively correlated with suicide rates across all countries industrialized or developing so far studied. Once again, aggregate figures can hide major discrepancies between, for example, rural and urban areas (for example, in China and the Islamic Republic of Iran).
Suicide is a leading cause of death for young adults. It is among the top three causes of death in the population aged 1534 years. As shown in two examples in Figure 2.5, suicide is predominant in the 1534-year-old age group, where it ranks as the first or second cause of death for both the sexes. This represents a massive loss to societies of young persons in their productive years of life. Data on suicide attempts are only available from a few countries; they indicate that the number of suicide attempts may be up to 20 times higher than the number of completed suicides.
Figure 2.5 Suicide as a leading cause of death, selected countries of the European Region and China,
Self-inflicted injuries including suicide accounted for about 814 000 deaths in 2000. They were responsible for 1.3% of all DALYs according to GBD 2000.
The most common mental disorder leading to suicide is depression, although the rates are also high for schizophrenia. In addition, suicide is often related to substance use either in the person who commits it or within the family. The major proportion of suicides in some countries of Central and Eastern Europe have recently been attributed to alcohol use (Rossow 2000).
It is well known that availability of means to commit suicide has a major impact on actual suicides in any region. This has been best studied for firearm availability, the finding being that there is a high mortality by suicide among people purchasing firearms in the recent past (Wintemute et al. 1999). Of all the persons who died from firearm injuries in the United States in 1997, a total of 54% died by suicide (Rosenberg et al. 1999).
The precise explanation for variations in suicide rates must always be considered in the local context. There is a pressing need for epidemiological surveillance and appropriate local research to contribute to a better understanding of this major public health problem and improve the possibilities of prevention.
Chapter 2: Burden of Mental and Behavioural Disorders:
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