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					                                                          Suicidologi 2002, årg. 7, nr. 2

    A global perspective
    in the epidemiology of suicide
    By José Manoel Bertolote, and Alexandra Fleischmann

    Global suicide rates and trends are presented, highlighting particularities of different countries in different regions
    of the world. The global data are examined with regards to sex, age and in relation to cultural factors
    (i.e. the prevailing religion) in countries. With regards to the prevention of suicide, the necessity of a local system
    of monitoring suicide trends is stressed.
    Introduction                                    point is acknowledged, which only rein-         quite distinct in relation to these charact-
      Since its foundation in 1948, the World       forces the gravity of the global picture of     eristics, such as Sri Lanka and Cuba.
    Health Organization (WHO) has been              suicide. Another question that is frequent-       Curiously enough, when the data are
    collaborating with its Member States in         ly raised refers to the comparability of data   separated by WHO region, the highest
    view of perfecting methods for obtaining,       across countries. The information present-      rates in each region with the exception
    processing and analysing data on mor-           ed here reflects the official figures made      of Europe, are found in island countries,
    tality and morbidity. As a result, WHO          available to WHO by its Member States;          such as Cuba, Japan, Mauritius and Sri
    maintains a data bank on mortality accor-       these, in turn, are based on real death         Lanka. Also, according to the WHO
    ding to the data provided by its Member         certificates signed by legally authorized       regional distribution, the lowest rates as
    States. Deaths from all causes are reported,    personnel, usually doctors and, to a lesser     a whole are found in the Eastern Medi-
    usually split by sex and age, along with        extent, police officers. Generally speaking,    terranean Region, which comprises mostly
    mid-year population data. The actual            these professionals do not misrepresent         countries that follow Islamic traditions;
    number of deaths in each demographic            the information, and the real dimension         this is also true of some Central Asian
    category is then transformed into rates.        of eventual distortions introduced by mis-      republics that had formerly been inte-
    The WHO data bank on mortality has              reporting remains to be demonstrated.           grated into the Soviet Union.
    grown from a few Member States in the           It is hoped that the figures presented can
                                                                                                      In Figure 1, global suicide rates (per
    early 1950s to more than 100 Member             provide a solid ground against which
                                                                                                    100,000 population) have been calculated
                                                    corrections and improvements can be
    States that reported at some point in time.                                                     starting from 1950. Deaths reported by
        Mortality associated with suicide is        brought about.
                                                                                                    countries in each year were averaged and
    part of the data bank. The regularity of        Suicide rates                                   projected in relation to the global popu-
    reporting on mortality has been varied.                                                         lation over 5 years of age at each respec-
                                                      According to WHO estimates for the
    Some Member States have been reporting          year 2020 and based on current trends,          tive year. An increase of approximately
    data since 1950 (11 countries); others do       approximately 1.53 million people will          49% for suicide rates in males and 33%
    not report at all. In 1985, the largest         die from suicide, and 10–20 times more          for suicide rates in females can be obser-
    number of countries reported on mortality       people will attempt suicide worldwide.          ved between 1950 and 1995.
    (74 countries) and by 1998 there were           This represents on average one death
    still 50 countries involved. Almost no                                                               Figure 1. Global suicide rates since
                                                    every 20 seconds and one attempt every
    data is available from the WHO African          1–2 seconds.                                         1950 and trends until 2020.
    Region, scarce information from the WHO                                                         35
                                                      Although it is customary in the suicido-
    South-East Asia and Eastern Mediterr-           logy literature to present rates of suicide
    anean Regions, and irregular information                                                        30             Men
                                                    for both men and women combined (the
    is sent from many countries of the Western      so called total suicide rates), it should be    25
    Pacific Region and from Latin American          noted that the current general epidemi-
    countries of the Region of the Americas.        ological practice is to present rates accor-    20
    From countries of the European Region           ding to sex and age, particularly when
    data are received mostly on a regular basis.    important differences (in terms of figures      15
       It is of special relevance to the field of   or risk factors) across sex or age groups                                 Women
    suicidology that the category name and                                                          10
                                                    exist. This is precisely the situation in re-
    code of mortality associated with suicide       lation to suicide; suicide rates of men and      5
    has remained relatively stable through          women are consistently different in most
    successive editions of the International        places, as are rates in different age groups.    0
    Statistical Classification of Diseases and        The highest suicide rates for both men        1950               1995            2020
    Related Health Problems (ICD), from             and women are found in Europe, more                              900,000         1,53 mio
    ICD-6 to ICD-10.                                particularly in Eastern Europe, in a group                    deaths reported     deaths
       Whenever figures on suicide are pre-         of countries that share similar historical                                       estimated
    sented or discussed there is always the         and sociocultural characteristics, such as
    question of their reliability, since in some    Estonia, Latvia, Lithuania and, to a lesser       The increase in these global suicide rates
    instances – and for several reasons – suicide   extent, Finland, Hungary and the Russian        must be interpreted with caution. On the
    as a reason for death can be hidden;            Federation. Nevertheless, some similarly        one hand, it might reflect the fact that
    therefore, real figures may be higher. This     high rates are found in countries that are      since the end of the USSR (which had

6                                 A global perspective in the epidemiology of suicide
                                                       Suicidologi 2002, årg. 7, nr. 2

an overall rate below the average), some          Absolute numbers of suicide                    globally speaking. Currently, more sui-
of its former republics (particularly those         In spite of the wide (and appropriate)       cides (55%) are committed by people
with the highest rates in the world) started      use of rates, the information conveyed         aged 5–44 years than by people aged 45
to report individually, thus inflating the        by them alone can be misleading, partic-       years and older (Figure 3). Also, the age
global rate. On the other hand, figures for       ularly when comparing data across coun-        group in which most suicides are currently
1950 were based on 11 countries only,             tries or regions with important differences    completed is 35–44 years for both men
and this gradually increased up to 1995,          in the demographic structure. As indicated     and women.
when the estimates were based on 62               earlier, the highest suicide rates are
countries that reported on suicide. These         currently reported in Eastern Europe;           Figure 3. Changes in the age
62 countries as a whole probably have             however, the largest numbers of suicides        distribution of cases of suicide
higher rates, they are more concerned             are found in Asia.                              between 1950 and 1998.
with them and they have a higher ten-               Given the size of their population, al-
dency to report on suicide mortality than         most 30% of all cases of suicide worldwide
countries where suicide is not perceived          are committed in China and India alone,                                   1950
                                                                                                     60%         40%
                                                  although the suicide rate of China practi-                                (11 countries)
as a major public health problem.
                                                  cally coincides with the global average
  Figure 1 also highlights the relatively         and that of India is almost half of the
constant predominance of suicide rates in         global suicide rate. The number of suicides
males over suicide rates in females: 3.2:1        in China alone is 30% greater than the
in 1950, 3.6:1 in 1995 and 3.9:1 in 2020.         total number of suicides in the whole of
                                                                                                    45%         55%
There is only one exception (China), where        Europe, and the number of suicides in                                     (50 countries)
suicide rates in females are consistently         India alone (the second highest) is equiva-
higher than suicide rates in males, particu-      lent to those in the four European coun-
larly in rural areas (Phillips and Zhang,         tries with the highest number of suicides              5–44 years           45 + years
2002).                                            together (Russia, Germany, France and
  As for age, there is a clear tendency for       Ukraine).
                                                    Given the relatively narrow differences        This ‘ungreying’ of suicide is a relatively
suicide rates to increase with age (Figure
                                                  in the population of males and females         new phenomenon. It becomes dramatic
2). Against a global suicide rate of 26.9         in each age group, the large predominance      when one considers that the proportion
deaths per 100,000 for men in 1998, the           of suicide rates among males is also found     of the elderly in the total population is
rates for specific age groups start at 1.2        in relation to the actual number of suicides   increasing at a greater rate than the one
(in the age group 5–14 years) and gradu-          committed.                                     of younger people. Also, it is not the re-
ally increase up to 55.7 (in the age group          It is in relation to age, however, that      sult of a divergent modification in suicide
over 75 years). The same positive relati-         the most striking changes in the picture       rates in these age groups: the suicide rate
onship between age and suicide rates is           are perceived when we move from rates          in young people is increasing at a greater
observed in relation to suicide rates in          to total numbers. Although suicide rates       pace than it is in the elderly.
females: for an overall rate of 8.2 in 1998,      can be between six and eight times higher
specific age group rates grow from 0.5 per        among the elderly, as compared with young      Suicide and cultural factors: the
100,000 (in the age group 5–14 years) to          people, currently more young people than       case of religious denomination
18.8 (in the age group over 75 years).            elderly people are dying from suicide,           A comparison of suicide rates according
           Figure 2. Distribution of suicide rates (per 100,000) by gender and age, 1998.        to the prevalent religious denomination
                                                                                                 in countries brings to light a most remar-
            60                                                                                   kable difference between countries of Islam
                                                                                                 and countries of any other prevailing
            50                                                                                   religion (Figure 4). In Muslim countries
                                         Males                                                   (e.g. Kuwait), where committing suicide
                                                                                                 is most strictly forbidden, the total suicide
 R A T E

            30                                                                                   rate is close to zero (0.1 per 100,000
                                                                                                 population). In Hindu (e.g. India) and
            20                                                Females                            Christian countries (e.g. Italy), the total
                                                                                                 suicide rate is around 10 per 100,000
            10                                                                                   (Hindu: 9.6; Christian: 11.2). In Buddhist
                                                                                                 countries (e.g. Japan), the total suicide
             0                                                                                   rate is distinctly higher at 17.9 per
        5–14              15–24    25–34     35–44    45–54     55–64     65–74      75+         100,000 population. At 25.6, the total
Males    1.2               19.2     28.3      34.7     39.7      41.0      41.5      55.7        suicide rate is markedly highest in Atheist
Females  0.5                5.6      7.7       8.4     10.5      11.8      14.1      18.8        countries (e.g. China) which included
                                        A G E     G R O U P                                      in this analysis countries where religious

                                  A global perspective in the epidemiology of suicide                                                            7
                                                         Suicidologi 2002, årg. 7, nr. 2

                                                                                                  It is, nevertheless, hoped that the infor-
             Figure 4. Suicide rates (per 100,000) according to religion.                        mation provided here can raise awareness
        45                                                                                       and evoke interest with regards to the
                   Total     Male      Female                                                    serious public health and community
        40                                                                                       burden represented by suicide.
                                                                                                 Phillips MR, Li X, Zhang Y. Suicide rates in China,
        30                                                                                       1995–99. Lancet 2002; 359: 835-40.
                                                                                                 World Health Organization. Primary Prevention
        25                                                                                       of Mental, Neurological and Psychosocial
                                                                                                 Disorders. Geneva: WHO, 1998.
                                                                                                 World Health Organization. Figures and facts
        15                                                                                       about suicide. Geneva: WHO, 1999.

        10                                                                                                           José Manoel Bertolote is
                                                                                                                     Coordinator of the Team on
         5                                                                                                           Management of Mental and
                                                                                                                     Brain Disorders, Department
         0                                                                                                           of Mental Health and Sub-
                Buddhist       Christian         Hindu        Muslim         Atheist
                 1986           1994             1995         1985,87        1995,96                                 stance Dependence, World
                                                                                                                     Health Organization,
                                                                                                                     Geneva, Switzerland.
    observances had been prohibited for a         in a country, in relation to suicide deaths,   One of his responsibilities is SUPRE, the WHO
    long period of time (e.g. Albania).           as a major cultural factor in the determi-     Global Initiative on Suicide Prevention. He is
      With regards to gender, the suicide         nation of suicide.                             also Associate Professor in the Department of
                                                                                                 Psychogeriatrics at Lausanne University,
    rates according to the prevailing religion    Prevention of suicide                          Switzerland.
    in countries are generally higher among                                                                          Alexandra Fleischmann is a
                                                    Global figures and statistics are very                           Clinical and Health Psycho-
    males than females. The highest male:         suitable for giving a broad view of a pro-                         logist working in the Team
    female ratio can be found in Atheist and      blem, raising awareness about it and pro-                          on Management of Mental
    Christian countries, namely 3.5:1 in both     viding a means of comparison with other                            and Brain Disorders, Depart-
    cases; the lowest is seen in Hindu coun-      problems. However, they hide important                             ment of Mental Health and
    tries, at 1.3:1. Certainly, these findings                                                                       Substance Dependence,
                                                  regional and local characteristics and                             World Health Organization
    do not take personal levels of religiosity    cannot replace a sound local system of                             (WHO), Geneva, Switzer-
    into consideration; however, they might       monitoring suicide trends, including           land. For the past few years, her main activities
    indicate the importance of the religious      sociodemographic, psychiatric and              have been related to the WHO Global Initiative
    context, i.e. the prevalence of a religion    psychological variables.                       on Suicide Prevention.

8                              A global perspective in the epidemiology of suicide

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