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RESEARCH REPORTS |
1 Estonian-Swedish Mental Health and Suicidology Institute, Estonian Centre of Behavioural and Health Sciences, Estonia
2 Tallinn University, Estonia
3 Trimbos-Instituut/Utrecht and VU Medical Centre, Institute of Extramural Research, Amsterdam, The Netherlands
4 University of Primorska, Koper, Slovenia
5 Directorate of Health Campaign Against Depression and Suicide, Seltjarnarnes, Iceland
6 Centre for Health Services Studies, University of Kent, UK
7 University of Bern, Department of Psychiatry, Bern, Switzerland
8 Katholieke Universiteit Leuven, LUCAS-Centre, Leuven, Belgium
9 National Suicide Research Foundation, Cork, Ireland
10 Vaasa Central Hospital, Psychiatric Unit, Vaasa, Finland
11 S Maurizo Hospital Bolzano, Bozen, Italy
12 Universidade Nova de Lisboa, Faculdade de Ciências Médicas, Lisbon, Portugal
13 Department of Applied Social Sciences, University of Stirling, UK
14 Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
15 Semmelweis University Budapest, Institute of Behavioural Sciences, Budapest, Hungary
16 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
17 University of Leipzig, Department of Psychiatry, Leipzig, Germany
Correspondence to:
Dr A Värnik, Estonian-Swedish Mental Health and Suicidology Institute, Õie 39, Tallinn 11615, Estonia; airiv{at}online.ee; airi.varnik{at}ipm.ki.se
Accepted for publication 13 July 2007
 | ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Design: Proportions of seven predominant suicide methods utilised in 16 countries participating in the European Alliance Against Depression (EAAD) were reported in total and cross-nationally. Relative risk (RR) relating to suicide methods and gender was calculated. To group countries by pattern of suicide methods, hierarchical clustering was applied.
Setting and participants: Data on suicide methods for 119 122 male and 41 338 female cases in 2000–4/5 from 16 EAAD countries, covering 52% of European population were obtained.
Results: Hanging was the most prevalent suicide method among both males (54.3%) and females (35.6%). For males, hanging was followed by firearms (9.7%) and poisoning by drugs (8.6%); for females, by poisoning by drugs (24.7%) and jumping from a high place (14.5%). Only in Switzerland did hanging rank as second for males after firearms. Hanging ranked first among females in eight countries, poisoning by drugs in five and jumping from a high place in three. In all countries, males had a higher risk than females of using firearms and hanging and a lower risk of poisoning by drugs, drowning and jumping. Grouping showed that countries might be divided into five main groups among males; for females, grouping did not yield clear results.
Conclusions: Research on suicide methods could lead to the development of gender-specific intervention strategies. Nevertheless, other approaches, such as better identification and treatment of mental disorders and the improvement of toxicological aid should be put in place.
Methods that individuals choose in suicide vary widely in their probability of resulting death. At least two general factors determine lethality by a particular method. Firstly, the time span between the initiation of a suicidal act and expected death is crucial for outcome. Highly lethal suicide methods are fairly quick, reducing the possibility of detection and intervention. Lethality is lower if the method chosen gives time for intervention, as well as the possibility of changing one’s mind and seeking help. Also critical for outcome is the availability of medical aid and its quality related to the method used.3
Male suicide rates greatly exceeded female rates in all European countries (http://data.euro.who.int/hfamdb/). Several studies have suggested that a primary reason for gender differences in completed suicides is the result of differences in methods used by the two groups.4–7
A number of factors may influence an individual’s decision regarding method in a suicide act. Hendin8 attributes choice of method to a form of final communication of both personal and social needs: a last message. He believes that this message is an expression of the life left behind and the individual’s hopes to resolve the conflicts that plagued him or her in life.
Different methods yield mixed results in terms of lethality. Therefore, there is no single answer to the question whether method choice can be used as a measure of suicidal intent. Similarly, a review of the literature reveals disparate conclusions. Some have found no significant gender differences between the level of suicidal intent,4 9 10 others have argued that women tend to use less lethal methods because they have less desire to kill themselves.3 6 11
Gender differences in the utilisation of suicide methods may depend on beliefs about culturally acceptable gender-specific self-destructive behaviours. If completed suicide is viewed as a masculine behaviour, then an attempted suicide does not suit the men’s role. Following this rationale, suicidal males could choose violent methods, as it would make them more likely to "succeed" in their action.9 Some attribute women’s use of less violent methods to their concern for bodily appearance—how they will look in death.11 12
The EAAD (European Alliance Against Depression), an international partnership of 16 European countries, established in 2004, aims to reduce suicide rates in participating countries by implementing evidence-based actions and creating recommendations for effective interventions.13 The EAAD intervention concept is partly based on experiences of the Nuremberg Alliance Against Depression, a model project that has been shown to be effective in reducing the number of suicidal acts.14 The epidemiological data on methods of suicide gathered in the course of this project provide an opportunity to contribute to the field of suicide prevention.
The present study reports the gender-specific suicide methods in 16 countries participating in the EAAD, compares the results between countries and makes efforts to group countries with similar patterns of suicide methods.
| METHODS |
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| TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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As data on method-specific suicide are not available through the WHO databank, the data were obtained from the appropriate statistics institutions of the EAAD countries. Specifically, the responsible institutions that provided the data are Belgium, Flemish Ministry of Health in cooperation with the National Institute of Statistics (Statistics Belgium); Estonia, Statistics Estonia (Statistikaamet) www.stat.ee; England, South East Public Health Observatory (SEPHO) www.sepho.nhs.uk; Finland, Statistics Finland (Tilastokeskus) www.stat.fi; Germany, Information System of the Federal Health Monitoring (Gesundheitsberichterstattung des Bundes) www.gbe-bund.de; Hungary, Hungarian Central Statistical Office; Iceland, Statistics Iceland www.statice.is; Ireland, Central Statistics Office (CSO) Ireland www.cso.ie; Italy (South Tyrol), Public Health Office of S Maurizo Hospital Bolzano (Servizio Igiene Ospedale S Maurizio Provincia di Bolzano); Luxembourg, (Ministère de la Santé) www.ms.etat.lu; The Netherlands, Statistics Netherlands (Centraal Bureau voor de Statistiek) http://statline.cbs.nl/; Portugal, Statistics Institute (Instituto Nacional de Estatística) http://www.ine.pt/portal/; Scotland, General Register Office for Scotland www.gro-scotland.gov.uk; Slovenia, Institute of Public Health and the Statistical Office of the Republic of Slovenia; Spain, National Statistics Institute (Instituto Nacional de Estatistica) www.ine.es; Switzerland, Swiss Federal Statistical Office (Bundesamt für Statistik) www.bfs.admin.ch.
The EAAD database contains suicide deaths registered with the above mentioned institutions responsible for health statistics of participating countries for the following years: 2000–5 in Estonia, Finland, Germany, Italy (South Tyrol county), Luxembourg, The Netherlands, Scotland and Spain, in 2000–4 in Belgium (Flemish Region, 59% of entire population), England, Hungary, Iceland, Ireland, Portugal, Slovenia and Switzerland. All suicide methods were re-categorised into eight groups using all ICD-10 X-codes (table 1). The category "other" includes methods that accounted for less than 3% of the overall number of suicides: explosive material (X75), fire (X76), hot vapours (X77), cutting/piercing with sharp object (X78), cutting/piercing with blunt object (X79), crashing of motor vehicle (X82), with other specified and classifiable means (X83) and other unspecified means (X84).
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= 0.05. | RESULTS |
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| TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Hanging was the most frequent suicide method among males in all countries except in Switzerland, where firearms ranked first. Firearms were the second most common suicide method among males in Belgium, Estonia, Finland, Germany and Slovenia. Use of firearms ranked lowest in Scotland (table 2).
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A comparison of male and female suicide methods showed that males have a statistically significantly higher risk than females of using firearms, hanging and poisoning by other means, and lower risk in poisoning by drugs, drowning and jumping (table 3). In all EAAD countries, males had a higher risk of hanging than females. The situation was similar for firearms; only in Italy did the male-female difference not reach statistical significance.
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Grouping with hierarchical clustering using the Ward method showed that countries might be divided into five main groups by suicide methods among males. The first group (Estonia, Slovenia, Hungary) had a very high proportion of hanging and low proportions of drowning and using a moving object as a mean. The second group (Finland and Switzerland) had the highest proportion of using firearms and the lowest of hanging in comparison with other countries; also poisoning by drugs was above average. The third group (Germany, Belgium and The Netherlands) had average proportions of hanging and poisoning by drugs. In countries in the fourth group (England, Scotland and Iceland), the proportion of poisoning by drugs was higher than in other countries and poisoning with other means was above average. The fifth group (Italy, Spain, Luxembourg and Portugal) had a high proportion of jumping along with a low proportion of using a moving object. Italy, Portugal and Spain also had low percentages of poisoning by drugs. Ireland could not be grouped with any other countries owing to its high proportion of drowning.
For females, grouping with hierarchical clustering divided countries into three triplets and three pairs. The first cluster consisted of England, Scotland and Hungary which all had high proportions of poisoning by drugs, low percentages of jumping and below average proportions of drowning. The second cluster, Germany, Slovenia and The Netherlands, was similar to the overall average. Estonia had a very high proportion of hanging and very low proportions of drowning and use of a moving object, consequently Estonia could not be grouped with any other countries. Finland and Switzerland each had high percentages of poisoning by drugs and low proportions of hanging. Belgium and Ireland had high proportions of drowning and low proportions of jumping. Italy, Luxembourg and Spain had very high proportions of jumping and low proportions of hanging. The last pair, Iceland and Portugal, ranked above average in drowning and low in the use of a moving object. Hanging was ranked below average.
| DISCUSSION |
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| TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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One of the limitations of the study was that two different classifications of causes of death were covered: in England, Ireland and Portugal the 9th revision of the ICD was used, which was replaced by X-coded death using ICD-10 in the other countries.
To verify that the EAAD sample could represent the whole of Europe in terms of suicide mortality, the average annual age-adjusted suicide rates between the years 2000–5 were compared. For EAAD countries combined suicide rates 16.3 for 100 000 males and 5.0 for 100 000 females was lower against suicide mortality of the whole of Europe (Commonwealth of Independent States included)—28.9 for males and 6.1 for females. The respective age-adjusted rates for 15 European Union member states (until 1 May 2004)—16.0 for males and 5.0 for females (average for 2000–4)—were similar to that of the average of the EAAD countries combined.
With respect to individual countries, there were several countries that were limited by non-representative samples: Belgium was represented only by the Flemish region and Italy was represented only by South Tyrol County. Also, two regions were reported separately in the United Kingdom. As England and Scotland are two separate sites in the EAAD study, they are reported here with caution as two separate countries.
To test the reliability of data obtained by EAAD partner countries, male and female suicide numbers were compared to WHO data in the European Mortality Database. There was agreement between the WHO data and the EAAD compiled data in Estonia, Finland, Germany, Hungary, The Netherlands, Portugal, Slovenia and Spain. For cites where a region, rather than the whole country was studied (Belgium, Italy, England and Scotland), data were not comparable with WHO data. There were some notable differences between EAAD and WHO data. The EAAD data for Ireland was 8.5% and for Luxembourg 1.8% higher than the WHO data. In contrast, the EAAD data from Iceland and Switzerland were lower—2.9% and 0.5% respectively.
Male and female suicide methods
Although completed suicide rates are generally much higher in men than in women with the exception of some Asian countries,15–17 there are more suicide attempts registered for females by the WHO/EURO Multicentre Study in most of the participating countries,16 and much more diagnosed depression in women relative to men.10 12 18 This gender paradox calls into question the possible reasons for different prevalence rates in male-female completed suicides.9 19
Several studies have addressed the issue of different patterns of methods used in male and female suicide populations as the primary reason for gender differences in suicide mortality. Traditionally, women have selected suicide methods that are less lethal and men have chosen techniques that are more violent and whose consequences are irreversible.3–5 20
Spicer et al7 revealed that firearms, drowning and suffocation/hanging were the most lethal methods and drug overdose/poison ingestion and cutting/piercing were the least lethal methods. In Card’s classification,21 in addition to the above mentioned methods jumping from a high place and jumping in front of a moving object were added to the highly lethal methods. Card qualified the use of fire as a less lethal suicide method.
The present study found hanging to be the most predominant method of suicide in all EAAD countries combined. In fact, 54.3% of males and 35.6% of females in our study died from hanging. As hanging is universally available, it makes sense that it is the most common suicide method in many countries worldwide22; however, there is considerable variability internationally. A study of suicide methods in a large number of cases in Japan and the United States revealed that Japan had a very high proportion of hanging (70.4% for males and 60% for females); this proportion was much lower (18.2% for males and 16.2% for females) in the United States.23 Similarly, an Australian study reported hanging in 32% of its cases.24 Hanging and self-poisoning with pesticides were the preferred means of suicide in south India.25
Self-poisoning (X60–X69) ranked as the second highest suicide method for both males (14.0%) and females (29.0%) in EAAD countries combined. In the EAAD this usually meant poisoning by drugs—that is, medication (X60–X64), in contrast to worldwide trends, which show that self-poisoning by pesticides is the frequently used method among other poisonings (X65–X69) in many Asian, African and Latin American countries, accounting in rural areas for about a third of all suicides worldwide.1 In fact, in rural China pesticide ingestion accounts for 58% of all suicides and accounts for 79% of all suicides among young females in rural areas.26
Firearms, a highly lethal method, ranked the third among males (9.7%) and were rarely used among females (1.3%) in EAAD countries combined. In the United States, respective proportions were much higher—63.1% and 37.2%.23 An Australian study24 reported the use of firearms in 22% of total suicides. In Japan23 and China27 the use of firearms as a means of suicide was rare. The literature on this topic shows that limiting access to firearms has been found to be an effective mean of reducing suicide mortality.28 29
Notwithstanding the similar rank order of suicide methods among males and females combined, males had a 7.2 times higher risk of using firearms and a 1.5 times higher risk of hanging than females, while poisoning by drugs and drowning were methods predominated by females. Remaining methods had different male-female dominance in different countries. Considering the classification systems of Spicer et al7 and Card,21 in European countries males had a higher risk of using more lethal methods like hanging and firearms than females.
Grouping countries
There was a strong similarity between Hungary, Slovenia and Estonia, based on very high shares of hanging both for males and females. In an effort to find an explanation, we note the following common features: recent socialist backgrounds, rapid socio-political and economic changes in integrating into the European Union, very high alcohol consumption, high rates of alcohol dependence and abuse among suicidents17 30–33 and high overall suicide rates.
Referring to the cluster analysis of male suicide methods, excluding the former Eastern block countries (Estonia, Hungary and Slovenia) and Finland and Switzerland, the remaining groups of countries appear, at the first glance, to be similar in suicide methods by geographic proximity. In northwest Europe (England, Scotland and Iceland), high proportions of poisoning by drugs were found. Central Europe (Belgium, Germany and The Netherlands) was close to the EAAD average concerning most methods and southern Europe (Italy, Portugal, Spain, including also Luxembourg) was characterised by a very high proportion of jumping. Ireland could not be grouped because of the extremely high level of drowning. It was surprising to find an almost congruent pattern of suicide methods for both genders in Switzerland and Finland characterised by high rates of poisoning by drugs and firearms and also low proportions of hanging. Such commonalities were not present in females and female clusters were not identifiable.
Prevention possibilities
The high rate of hanging places considerable limitations on the reduction of suicides through method restriction except in institutional settings.34 35 De Leo et al24 associated hanging with having low impulse control, being in short-term, suicidal crisis and receiving past or current psychiatric treatment. They called for further investigations to develop a deeper understanding of hanging and to develop appropriate prevention methodologies. Cantor and Baume34 also pointed out that little research has examined hanging and suggested hanging might be influenced by changing public perceptions of the social acceptability of suicide by hanging.
Self-poisoning, as a potentially preventable method,28 36 should be the topic of further investigations regarding the promotion of suicide prevention policy. X-classification offers the opportunity to assess the use of self-poisoning as a suicide method. A cross-sectional global public health initiative with the overall goal of reducing morbidity and mortality related to pesticide poisoning has been announced by the WHO.1 Self-poisoning by drugs accounts for one fourth of female deaths in EAAD countries and in some of the countries almost a half of female suicides. As such, self-poisoning deserves attention and the application of best practices in the field.
There are remarkably few papers on suicide prevention addressing gender issues on method choice.37 Identifying and comparing patterns of methods of suicides used in different countries by gender could lead to the development of intervention strategies. The present study identifies groups of countries with similar patterns of suicide methods by gender and encourages the research and development of collaborative suicide prevention strategies. Nevertheless, control of access to methods is but one of the strategies for suicide prevention. Other approaches, such as better identification and treatment of mental disorders and the improvement of toxicological aid, should be put in place.
Further analysis of other sociodemographic correlates is warranted, particularly the age distribution of the utilisation of suicide methods and a detailed analysis of poisoning by drugs as a preventable method to complete suicide.
What is already known on this subject
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What this study adds
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Policy implications Research on suicide methods, taking into account best practices in restriction of means, could lead to the development of effective intervention strategies.
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| FOOTNOTES |
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| REFERENCES |
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ic A, Landau S, Tomori M. Long-term trends, seasonality, weekly distribution, and methods of suicide in Slovenia: a comparison between the younger and older population. Arch Suicide Res 2003; 7: 135–43.[CrossRef]Relevant Article
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS | REGISTER |
