Epidemiology and Causes of Suicide
Jouko K. Lonnqvist
Definition of suicide and the reliability of suicide statistics
Suicidal behaviour or suicidality can be conceptualized as a continuum ranging from suicidal ideation and communications to suicide attempts and completed suicide. A developmental process which leads to suicidal ideation, suicidal communication, self-destructive behaviour, in some cases even to suicide, and its consequences to the survivors is often referred to as a suicidal process. There is no single unanimously accepted definition of suicide, although in most proposed definitions it is considered as a fatal act of self-injury (self-harm) undertaken with more or less conscious self-destructive intent, however vague and ambiguous. Since the deceased cannot testify as to his or her intent, the conclusions about this must be drawn by inference. The evidence required for this inference depends on many factors, for example the mode of death, the use of autopsy, age, gender, social and occupational status, and the social stigma of suicide in the person’s culture. The assessment of suicide intent is always based on a balance of probabilities.
Besides the conceptual problems, there are differences in operational definitions of suicidal behaviour which may lead to lack of uniformity of case definition and difficulties in comparing suicide statistics. The reliability of suicide statistics is influenced by whether suicide is ascertained by legal officials as in the United Kingdom and Ireland, or by medical examiners as elsewhere in Europe. In general, suicides tend to be undercounted, whereas non-suicidal deaths are very rarely misidentified as suicides. Most misclassified suicides fall into the category of undetermined deaths and are more like suicides than accidents. Underestimation is reasoned to be less than 10 per cent in the more developed countries, which allows rate comparisons between countries and over time. Despite problems in the recording of suicide, reports on suicide rates among different cultures or people suggest a true variation in suicide mortality.(1,2)
The suicide process and the act of suicide
Suicide is a mode of death usually consequent to a complex and multifaceted behaviour pattern. It is typically seen as the fatal outcome of a long-term process shaped by a number of interacting cultural, social, situational, psychological, and biological factors. Suicide is a rare, shocking, and very individual final act, which often leaves the survivors helpless. The suicide process model is used to organize and clarify the complexity of factors associated with suicide (Fig. 4.15.1.1).
Suicide is usually preceded by years of suicidal behaviour or feelings, and plans and warnings. In about half of all suicides, a previous attempt is found in the person’s history, which offers, in theory, an opportunity for suicide intervention wherever suicide attempts occur. Male suicide attempts are more violent and the first attempt more likely to end in death. Successful suicide prevention calls for sensitive understanding of suicidal intent and active early intervention.(3)
Various risk or protective factors underlie suicidal behaviour. An appearance of suicidality means either an intensified effect of risk factors or a weakened effect of protective factors. For example, a separation from someone close may precipitate a suicidal imbalance in a vulnerable person due to the adverse life event as a stressor and the broken social network as a loss of social support.
 Fig. 4.15.1.1 The suicide process model. |
The treating personnel and relatives of the suicide victim tend to overemphasize the meaning of the most recent events in the course of the suicide process. A precipitating factor may well be decisive in explaining the precise timing of suicide in the long course of a person’s suicide process. Often, however, it also allows a simple and rational explanation in the face of the complexity of suicide.
The choice of a specific method takes place at the very end of the suicide process and represents the last possibility to intervene. Hanging is universally available and it is the most common suicide method globally. In many countries the ready access to firearms makes them potentially dangerous, especially among male adolescents and young adults. Restricting access to handguns might be expected to reduce the suicide rate of young people. Previously, domestic gas was frequently used as a suicide method, and detoxfication resulted in a significant decrease in suicide rates. Nowadays, the increasing suicide rate in many Asian societies has been largely linked with pesticides and other poisons. Restrictive availability of lethal measures may also be important in the clinical treatment of individual suicidal patients. Restriction in availability of dangerous means is a strategy based on the fact that suicidal crises are often brief, suicidal acts are often impulsive, and the long-term suicide rate of serious suicide attempts is remarkably low.(4, 5 and 6)
Firearms, carbon monoxide, and hanging are active suicide methods with the highest potential to cause death. Jumping from a height or leaping in the front of a moving vehicle are more passive ways, but are also highly damaging in nature. Poisoning, drowning, or wrist cutting are typically methods which leave more time for help seeking and intervention.
Imitation means learning the use of a specific suicide method from a model which is overtly available in a culture, community, institution, or mass media. Imitation may have a significant effect on the choice of a suicide method, especially at schools, in psychiatric hospital wards, and in the general population of young people. The most famous example of imitation is the effect of Goethe’s novel The Sorrows of Young Werther, which was widely read in Europe about 200 years ago. The suicide of the hero was imitated to such an extent that authorities in several European countries banned the novel. The ‘Werther effect’ also appeared after the death of Marilyn Monroe; the suicide rate rose about 10 per cent over the next 10 days. Recommendations for reporting of suicide have encouraged avoidance of repetitive and excessive reports, descriptions of technical details, simplified explanations for suicide, presenting suicide as means of coping with personal problems, or glorifying suicide victims.(7)
Most suicides are solitary and private, but a few result from a pact between people to die together. Suicide pacts are exceptional, accounting for less than 1 per cent of all suicides.
Suicide always has a major impact on the survivors. Suicide is a threatening event not only among close family members, but also in the surrounding population, including treating personnel and the people at the victim’s workplace. The major challenges after a suicide, in addition to a normal mourning process, are dealing with shame and guilt feelings, and the crisis of survivors. Sharing of the traumatic experience and social support should be arranged immediately and continued, if necessary, at least some months after the suicide.
Epidemiology and public health aspects of suicide
Every year one million people commit suicide, accounting for 1 to 2 per cent of total global mortality. Suicide is a leading cause of premature death, especially among young adults. It is the fifth highest cause of years of life lost in the developed world. In many westernized countries, suicide is a more frequent cause of death than traffic accidents. According to World Health Organization (WHO) statistics, the annual world-wide incidence of completed suicide was 16 per 100 000 persons in 2000. This means that globally one person commits suicide every minute. Suicide is estimated to represent two per cent of the total global burden of disease.
The long-term trend in suicide mortality has been increasing at least during the last 50 years. The rank order of suicide mortality in the European region in 2001 to 2003 shows that most of the countries with high suicide mortality are located in Eastern Europe (Table 4.15.1.1). Outside this region, suicide mortality has been high in Japan and China. Everywhere, the male suicide rate is clearly higher than the female rate; China is the only exception with a very high female suicide rate.
The suicide rate of elderly people has been higher than in the younger age groups almost universally. However, in many Western countries, the suicide rate for people aged 65 years and over has been declining for decades. This change is associated with the growth of the general well being and the better social and health services.
Traditionally the incidence of suicide has been low in the younger age group (15-24), but during the past 40 years the suicide rate has been rising in many Western countries, especially among young males.
Table 4.15.1.1 Suicide rates per 100 000 by country, 2001-2003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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A long list of major public health concerns in the field of suicidology has emerged:
suicidal ideation and suicide attempts are surprisingly common in the general population
the high rate of suicides among adolescents and young adults
unemployment as a major risk factor for suicide
easy access to lethal suicide methods such as psychotropic or analgesic drugs, guns, and motor vehicles
high alcohol consumption and increasing substance misuse
undertreatment of major psychiatric disorders such as depression and schizophrenia
suicide models projected by the mass media.
These findings indicate that rapid growth and continuous changes in society are simultaneously causing instability and disturbing the development of integration. Some regions and groups of people are inevitably affected negatively by this development, and large numbers of people are thus moving towards a greater risk of suicide.
Determinants of suicide
Usually, suicide has no single cause. It is the endpoint of an individual process, in which several interacting determinants or risk factors can be identified (Tables 4.15.1.2 and 4.15.1.3). Risk factors are by their nature cultural, social, situational, psychological, biological, and even genetic.(8)
(a) Cultural factors in suicide
Culture defines basic attitudes towards life and death, and also towards suicide in society. We still have stigma against suicide. A hundred years ago, suicide was illegal in many European countries. Similarly, most churches overtly opposed suicide and allowed suicide victims to be buried only outside the cemetery. Religion was also a major integrating force between individuals and the community. In a modern secularized society, religion is still a meaningful and protective factor for many individuals in a suicidal crisis. Western culture has had a tendency to emphasize the individuals’s free will and the shouldering of responsibility for one’s life, while egoistic and anomic trends in society have intensified and altruism has almost disappeared. Such changes may have increased the incidence of suicide in society. The cultural background of suicide is a deep structure inherited over generations. Cultural factors also prevent rapid changes in suicidal behaviour, which is evident among immigrants, whose mode and rate of suicide usually lie somewhere between the original and the host cultures.(9)
Table 4.15.1.2 Risk factors for suicide: sociodemographic variables | ||||||||||||||||||||||||||||||||
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