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Gender differences in completed and attempted suicides
Gender Differences in Completed and Attempted Suicides EVE K. MOSCICKI,
ScD,
MPH
Attempted suicides occur primarily among women, while completed suicides occur primarily among men. Risk factors for both attempted and completed suicides include mental and addictive disorders, disrupted family environments, and precipitating events. This article presents an overview of findings on gender differences from epidemiologic studies of completed and attempted suicides, with a focus on suicide attempts among women, and discusses possible TeaSons for gender differences in suicidal behaviors. Ann Epidemiol 1994;4: 152-l 58. KEY WORDS:
Attempted suicide, gender, risk factors, suicide.
lumbia to 24.5/100,000
INTRODUCTION Completed
and attempted suicides are relatively rare events
that arise from a complex web of risk factors (1). They are extreme occurrences in a cluster of self-destructive behaviors that include less severe behaviors, ideation,
as well as increasingly
cluding suicidal ideation
such as casual suicidal
pathologic
behaviors,
with detailed plans,
in-
self-injury
without intent to die, failed suicide, and completed suicide. Attempted
and completed suicides share many underlying
characteristics,
but there also are important
tween them, including gender differences. understand
differences beIt is difficult to
attempted suicide, especially attempted suicide
among women, without understanding
the intricate prob-
lem of suicide itself. This article, therefore, from epidemiologic
studies of both
reviews findings
attempted
and com-
pleted suicides, with a primary focus on attempted suicides among women.
in Nevada (2). Traditionally,
suicide
rates have been highest in western states (l), with Vermont the single eastern exception
among the top ten.
Suicide rates differ by age, gender, and race. The 1990 age-adjusted
suicide rate for women was 4.5/100,000;
the
rate for men was 19/100,000 (2). The ratio of male to female suicide rates was thus 4.2. Consequently,
the scientific and
public focus has been on men and more recently on youth, because of their higher rates. The 1990 age-adjusted suicide rate for white women (4.8/ 100,000) was less than one-fourth (20.1/100,000) (2.4/100,000)
the rate for white men
(2). The age-adjusted rate for black women was less than one-fifth the rate for black men
(12.4/1000,000).
The distribution
of suicide rates for both
white and black women was fairly flat across age groups, with slightly higher rates for white women aged 35 to 59 years (Figure 1). The numbers of suicides for black women above age 50 were so low (< 20 in each 5-year age group) that age-specific rates were not estimated (2). In contrast to the similar age distributions
EPIDEMIOLOGY Incidence
OF COMPLETED
and Sociodemographic
SUICIDES
Characteristics
Suicide is the eighth leading cause of death in the United States. In 1990, the most recent year for which final mortality data are available, there were 30,906 suicide deaths, rep resenting 1.4% of the total number of deaths (2). Of these,
the age distributions
for black and white women,
for black and white men differed (see
Figure 1). Suicide rates for white men increased with age, while rates for black men peaked at ages 25 to 29, declined to age 65, and then peaked again at ages 70 to 74. These gender, race, and age-specific patterns also are evident when period and cohort effects are controlled
for (4).
6182 were committed by women. Homicide and suicide combined are the fourth leading cause of potential years of
Risk Factors
life lost (3). Suicide rates vary widely from state to state, and in 1990 ranged from 6.1/ 100,000 in the District of Co-
Systematic efforts to understand suicide began with Durkheim’s classic work in the late 19th century (5). With increasingly rigorous scientific work, including the application of multivariate
From the Prevention Research Branch, National Institute of Mental Health. Rockville. MD. Address reprint requests to: Eve K. MoScicki, ScD, MPH, Prevention Research Branch, National Institute of Mental Health, Room 10-85, 5600 Fishers Lane, Rockville, MD 20857. Received June 11, 1993; revised September 6, 1993. 0 1994b Elsevier Science Inc.
models in epidemiologic
studies of both com-
pleted and attempted suicide, has come increasing understanding of the interrelated risk factors for suicide. Although most research has been done in men, many risk factors
are believed
to be applicable
to both
men and
women. 1047.2797/94/$07.00
153
MoScicki GENDER DIFFERENCES IN SUICIDE
AEP Vol. 4, No. 2 March 1994: 152-158
Rates per 100,000 80 I
60
20
0 15-19 10-14
25-29
35-39
20-24
30-34
45-49 40-44
5-Year
55-59 50-54
65-69
65t
75-79
60-64
70-74
60-84
Age Groups
FIGURE 1. Suicide rates per 100,000 population by gender, race, and S-year age groups, United States, 1990. Rates were not calculated when based on fewer than 20 deaths. (Unpublished data from the National Center for Health Statistics.)
Suicide is a complex behavior with multiple risk factors, which fall into two broad categories-distal
and proximal.
Distal risk factors represent the foundation
on which events
Postmortem
studies have found reduced serotonergic
ity in the brains of suicide victims (20, 21), although not clear whether the effect of serotonin
associated with suicidal behavior are built, but do not lead
behaviors
directly to attempted
cific psychiatric
include underlying
or completed
psychiatric,
suicide. Distal factors
biologic,
(6). The strongest observed associations
and familial risks are for psychiatric
activit is
levels on suicidal
is direct, or whether it is mediated through spedisorders (18, 22).
Proximal risk factors are precipitating
circumstances
sociated with the suicide event itself. In combination
aswith
disorders (1, 6). More than 90% of completed suicides are
strong distal risk factors such as mental or addictive disor-
associated with mental or addictive disorders (7-9), the most
ders and a disrupted familial environment,
common of which are depression, personality disorders, and
factors contribute
alcohol abuse (7-10).
for suicide. Such “triggering” events are likely to differ with
Comorbid
occurrence
of more than
one psychiatric disorder, or comorbid mental and drug use disorders have been found frequently
(7, 8, 11, 12), sug-
proximal
risk
to the necessary and sufficient conditions
age, gender, ethnicity,
and other sociodemographic
factors.
The presence of a firearm in the home has been shown
gesting that completed suicide is associated with more severe
to be a major situational
forms of mental illness. It is likely that distal risk factors
Firearms account for nearly 60% of all suicide deaths; it is
are necessary, but not sufficient, for suicide to occur (7). Other distal risk factors include a family history of suicide and/or mental or addictive disorders (13, 14), and a disrupted family environment vorce, widowhood,
as defined by separation,
di-
or family violence. Suicide rates for di-
vorced and widowed women and men are higher than rates
factor in suicide deaths (23-25).
the method of choice for both men and women, followed by drugs and medicaments’
for women and hanging
for
men. Other alcohol,
proximal
risk factors include intoxication
with
crack cocaine, or other drugs (26, 27); recent, se-
vere, stressful life events such as the death of a spouse
for married persons (1, 15). In the case of divorce or separa-
(among young people, the sudden death of a friend or ac-
tion, it is not clear whether the disruption of the marriage
quaintance);
itself leads to suicide, or whether persons who are more likely to be suicidal also are more likely to be in an unstable
to the suicidal behavior of others (29); economic problems (28); finding oneself in jail (28, 30); and being diagnosed
marriage. A family environment
that includes violence in
with acquired
interpersonal
loss or rejection
immunodeficiency
syndrome
(28); exposure
(AIDS)
(3 1).
the form of physical and sexual abuse also may contribute to suicide risk (16, 17). In addition, there is consistent
evi-
dence that biologic risk factors may be associated with suicide and suicidal behavior
and with impulsivity (18, 19).
’“Medicaments” is the term used by the National Center for Health Statistics to classify self-inflicted deaths from medicinal agents.
154
Mdcicki GENDER DIFFERENCES IN SUICIDE
AEP Vol. 4, No. 2 March 1994: 152-158
One precipitating factor that has long been thought to con-
of the attempters, and the most common method of attempt
tribute to suicide, particularly in older adults, is the presence
was self-medication,
of a chronic
attempts (43).
or terminal
illness. Physical illness, however,
has not been shown to be an independent suicide outside the context psychopathology
accounting for 70 to 90% of all reported
risk factor for
A recent study based on surveillance of Oregon hospitals
of clinical depression or other
in 1988 reported an annual attempted suicide rate of 214/
(32).
100,000 for children (36). Eighty-four
and adolescents
aged 10 to 17 years
percent of the attempters
were females.
The most common method used by suicide attempters was EPIDEMIOLOGY
OF ATTEMPTED
drug overdose,
SUICIDE
which accounted
for 76% of all reported
attempts. The ratio of attempted to completed suicide rates
between Completed and Attempted Suicides
was estimated at 47. No data were collected for adults.
Although
Community
Differences
completed and attempted suicides have common
characteristics,
there also are important differences, limiting
the generalizability of findings between populations of completers and attempters.
One important
difference
is that
nearly 80% of suicide completers are men, while the majority of attempters are women. Another
is that not all attempters
injure themselves with the intent to die. Even when there is a strong intent to die, not all attempters injure themselves severely enough to cause death (33). Numerous
studies have shown attempted
suicide to be
a strong risk factor for completed suicide (7, 10,34). It generally is not considered
to be a clinically reliable predictor,
however, since it will generate a large proportion
of false-
positives, especially among younger age groups (35-37). One difficulty with predicting completed suicide based on a reported or observed attempt is associated with the measurement of severity of the attempt and the amount of suicidal intent associated with it (33, 38, 39). Self-inflicted
injuries
that are labeled as attempted suicides range widely in severity from a “cry for help” without intent to die to a genuine failed suicide. Some progress has been made in this area with the recent use of medical lethality as an index of severity, which appears to be an adequate way of distinguishing between most failed suicides and cries for help (33, 40-42). However it is defined (or not, in many studies), attempted suicide is an extreme form of behavior
and an expression
of distress that in and of itself merits study.
Studies
Lifetime data from the few community been conducted demonstrate on hospital data (44-46).
There are no national, population-based
men; other studies (45,46) did not report separate estimates of attempts by gender, but did note that risk was higher in women.
All of these reports suggested that attempted
suicide occurred more frequently
suicide. Weissman (43) reviewed English-language studies on attempted suicides between 1960 and 197 1, nearly all of
among persons with high
levels of psychiatric symptoms or with psychiatric diagnoses, especially depression (44-46). The best available prevalence
data on suicide attempts
among adult women in the general population
come from
the National Institute of Mental Health (NIMH) Epidemiologic Catchment
Area Study (ECA) (38). Detailed descrip-
tions of the methodology elsewhere (38,47-5
and initial findings have appeared
l), and can be summarized here. Briefly,
the purpose of this five-site study was to measure selected psychiatric
disorders and sociodemographic
the population.
risk factors in
Data were collected from 18,571 adults 18
years and older at two points in time, 1 year apart. Information on psychiatric symptoms was obtained using the Diagnostic Interview Schedule (DIS) (52,53), psychiatric
a highly structured
interview designed to be administered
by lay
interviewers. Diagnoses of psychiatric disorders were generated by computer algorithm according to standardized criteria established Psychiatric
data on attempted
Schwab and colleagues (44) found
lifetime attempt rates to be 4.0% for women and 1.2% for
in the Diagnostic
Mental Disorders,
Prevalence
studies that have
findings similar to those based
and Statistical
third edition (DSM-III)
Association
Manual of
of the American
(54).
The DIS included questions on thoughts of death, desire to die, suicidal ideation,
and suicide attempts.
rates were weighted to be representative
Prevalence
of the US popula-
which reported on data from hospital admissions. As might
tion. Initial analyses of these data indicated
be expected, there was a great deal of variation among stud-
prevalence
ies in completeness of coverage and data quality. Crude annual rates of attempted suicide ranged from 43/100,000
compared
in New Delhi to 730/100,000 in London, Ontario. With the exception of the New Delhi study, all reported a higher
attempted suicide was a lifetime diagnosis of any psychiatric
frequency of attempts by women than by men, with gender ratios ranging from 1.3 to 3.0. Weissman found that persons less than 30 years old frequently accounted for 50% or more
of attempted
that lifetime
suicide among women was 4.2%
with 1.5% among men, with an adjusted odds
ratio of 3.3 (38). The strongest independent
risk factor for
disorder, with an odds ratio of 8.4 (38). In order to determine whether the occurrence
of at-
tempted suicide was associated with severity of psychopathology, an index of severity was constructed based on the
155
MoScicki GENDER DIFFERENCES IN SUICIDE
AEP Vol. 4, No. 2 March 1994: 152-158
number of clinical diagnoses. The sample was grouped into
black males = 0.8%), there were no statistically significant
persons with no psychiatric
more than one diagnosis, and compared on the proportion
differences between race and gender groups (42). Significantly increased risk for all suicide attempts was found to
diagnosis,
one diagnosis,
and
of suicide attempts, stratified by gender. Women had greater
be associated with aggressive behaviors,
rates of attempted suicide regardless of the number of diag-
hol use, and illicit drug use. Odds ratios increased in magni-
noses. In both men and women, persons with more than
tude for attempts requiring medical care, with the highest
one diagnosis had the highest rates of attempted
suicide
cigarette use, alco-
odds ratios associated with intravenous
drugs and cocaine
cantly by gender. Odds ratios were 3.8 for women with one
use (42). Andrews and Lewinsohn (41) conducted a detailed study
lifetime diagnosis (95% confidence
of psychiatric disorders in a representative cohort (n = 17 10)
(men = 7.3%; women = 21.8%). Risk did not differ signifiinterval (CI), 2.9 to 4.9)
and 17.3 for women with more than one lifetime diagnosis
of high school students in five communities
(95% CI, 13.4 to 22.3), compared with women who had no
Oregon. Attempted suicides were rated for medical lethality
psychiatric
diagnosis.
Odds ratios were 4.1 for men with
in west central
and intent to die. The lifetime rate of attempted suicide at
one lifetime diagnosis (95% CI, 2.2 to 7.7) and 18.7 for men
baseline was 7.1%; the rate for females, lO.l%,
with more than one lifetime diagnosis
10.7 to
cantly greater than the rate for males, 3.8%. Thirteen (0.7%)
diag-
of the attempts reported by 12 1 adolescents were considered
32.6), compared
(95% CI,
with men who had no psychiatric
medically lethal,
nosis.
was signifi-
and six (0.35%)
were given the highest
rating on intent to die. Lethality
and intent were signifi-
cantly correlated (0.67). There were no gender differences
Recent Attempted Suicides in the Community
in lethality. At follow-up, 2.2% of females and 1.1% of males
Lifetime data are subject to recall bias, since they are heavily
reported having attempted suicide in the 12-month period
dependent
prior to interview, but the gender differences were not statis-
on a person’s ability to remember
important
events. Since women are generally considered to be better
tically significant.
reporters of health history than are men, as well as more
reported for the follow-up period. One of the most striking
frequent
findings of this study was the extremely
users of health services, the higher lifetime rates
of attempted suicide among women may not represent patterns of recently attempted
suicide in the population.
Later analyses of the ECA data addressed this potential bias by examining
l-year prevalence of attempted suicide.
Medical
lethality
and intent
were not
high proportion
of attempters who met criteria for at least one psychiatric diagnosis at both baseline and follow-up. Eighty percent of attempters
at baseline and nearly 100% at follow-up were
diagnosed with major depressive episode, alcohol and other
The prevalence of recent attempted suicide in the year prior
drug use disorders, and/or a disruptive behavior
to baseline was 22/100,000.
The prevalence was 19/100,000
There were no gender differences in the proportion
in the year prior to follow-up (55). There were no significant
tempters diagnosed with any of the disorders (41).
disorder. of at-
gender or age differences for either prevalence period. The estimated overall ratio of attempts to completions When
stratified by gender,
however,
was 18.
the estimated
ratio
was 8 for men and 59 for women, reflecting the much lower rates of completed suicide for women. Multivariable
condi-
tional logistic regression analyses showed that the most pow-
GENDER DIFFERENCES BEHAVIORS
IN SUICIDAL
The gender differences between rates of completed suicide
erful risk factors for recent attempts were recent major de-
and lifetime rates of attempted
pressive episode, recent alcohol abuse or dependence,
significant gender differences in recent attempted suicides,
any
suicides, and the lack of
recent cocaine use, and divorced or separated marital status
present an intriguing epidemiologic
(55). These risk factors for attempted suicide are identical to
Several plausible explanations
problem.
have been proposed, some
the distal risk factors most frequently reported for completed
more plausible than others. First, there is the lethality expla-
suicides.
nation; that is, gender differences between
Two studies of suicidal behaviors in community
popula-
completions
can be explained
tions of adolescents also failed to find gender differences for
method.
medically lethal attempts (4 1, 42). Garrison
commit suicidal acts in equal proportions,
(42) analyzed data from the Youth in South Carolina.
more suicide behaviors
in the past 12 months although
Risk Behavior
Survey
They found that high school females
reported significantly However,
and associates
of all kinds
than did males, regardless of race.
the proportion
of attempts
requiring
This explanation
attempts
by the choice
and
of suicide
assumes that men and women and that all sui-
cidal acts are intended to result in death. Since men choose more lethal methods, however, their suicidal acts are more likely to result in death. The lethality explanation is frequently encountered in the literature (e.g., [36]). It does not take into account intent to die, however, and disregards
medical treatment was slightly higher among females (white
the role of self-injury as a signal for help. It also does not
females = 1.9%, black females = 2.3%, white males = 1.2%,
offer reasons as to why men use more lethal methods, partic-
156
MoScicki GENDER DIFFERENCES
AEP Vol. 4, No. 2 March 2994: 152-158
IN SUICIDE
ularly in light of the fact that a firearm, an especially lethal
but simplistic prevention
means, is the method of choice for both men and women.
tiveness has been demonstrated
A second explanation time suicide attempts
for the greater frequency
reported
by women
efforts. Neither efficacy nor effecfor any existing suicide pre-
of life-
vention program. Indeed, the ability to predict which indi-
is recall bias.
viduals will die by suicide continues to be marginal (IO, 35).
Women are known to be better reporters of health history,
The preponderance
of powerful distal risk factors, espe-
and since most suicide attempt data from community studies
cially mental and addictive disorders, implies that a simplis-
are self-reported,
tic focus only on proximal or precipitating
this may explain in part the higher rates
among women.
risk factors is
unlikely to result in a substantial reduction of either suicide
A third explanation
to account
for differential
gender
attempts
or deaths.
Distal risk factors
also must be ad-
rates may be gender differences in socialization. According
dressed. Preventive
to this explanation,
intensive, and long-term as the behaviors they are intended
there are gender differences in culturally
interventions
need to be as complex,
acceptable self-destructive behaviors (56). Men are less likely
to prevent in order to have lasting effects over time (60).
to attempt suicide because attempts are considered
Ideally, prevention
“femi-
nine.” At the same time, men are more likely to engage in “masculine” self-destructive
behaviors
such as alcohol and
programs
risk factors simultaneously.
should address an array of
For example, suicide prevention
efforts need to be embedded in programs that address distal
other drug abuse, or use more aggressive and lethal methods
risk factors such as mental health and substance
of self-destruction
well as proximal
(57). This explanation
ported by the over-representation
is indirectly sup-
of men among chronic
abuse, as
risk factors such as responsible
firearm
ownership. Such programs are admittedly difficult to imple-
liver disease and cirrhosis deaths (2), by the large proportion
ment and monitor.
of men completing
and tested, however, the best hopes for prevention of suicide
suicides who were found to be intoxi-
cated at the time of death (7,8,26),
and by the large propor-
tion of men who commit suicide by means of firearms (37). The increased prevalence
Until such programs can be designed
and suicidal behaviors treatment
are identification
of mental and substance
and appropriate
abuse disorders.
of suicide with age among men
may indicate that women, especially older women, may be more willing and flexible in adapting to changing life situations than are men as a result of a lifetime of socialization and developmental
experiences.
less likely to respond
They
to severely
therefore
stressful
may be
life events,
such as the death of a spouse, with lethal self-destructive behavior (57). A fourth explanation
for the gender differences may be
found in the differential rates of depression and alcohol abuse. Women have higher incidence and prevalence rates of depression,
higher rates of recurrent
treatment
episodes,
and higher
rates, than do men (51, 58, 59). Men,
other hand, have higher rates of alcoholism abuse (51, 58). Clinical
depression
on the
and alcohol
is strongly
associated
with both completed and attempted suicides, and the higher lifetime rates of attempted suicide may be explained by overall higher rates of clinical depression among women. This explanation of completed
is not consistent with the higher observed rates suicide in men, however.
It is possible that
the lower rates of completed suicide among women may be explained in part by higher treatment
rates for depression.
That is, women in a major depressive episode may be as suicidal as men, but successful treatment for depression attenuates its severity and prevents suicide.
IMPLICATIONS
FOR
IMPLICATIONS
FOR
RESEARCH
The problem of gender differences
in suicide complicates
an already complex issue, and offers an interesting scientific challenge to epidemiologists.
The explanations
for gender
differences in suicide that have appeared in the literature, summarized above, can be examined logic hypotheses.
as testable epidemio-
In order to better understand
the gender
differences in completed and attempted suicides, however, it is first necessary to understand differential gender distributions
the reasons behind the
in the primary risk factors
for suicide, mental and addictive disorders. For example, although it is clear that severity and comorbidity
of psychi-
atric disorders are associated with both attempted and completed suicide, is the differential gender distribution chopathology Alternatively,
influenced
by severity,
and
in psy
if so, how?
how is severity of disorder mediated by gen-
der? How do distal and proximal risk factors interact with each other and with gender to produce attempted or completed suicide in women and men? Are there gender-specific biologic or environmental factors that protect women against certain psychiatric them from completed
disorders that also may protect
suicide? These and other questions
need to be examined in order to make meaningful progress in efforts to prevent attempted and completed suicides.
PREVENTION
Despite its complexity, a great deal has been learned about suicide and suicidal behaviors. Unfortunately, the scientific approach has not been widely applied to most well-meaning
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40. Brent DA. Correlates of medical lethality of suicide attempts in children and adolescents, J Am Acad Child Adolesc Psychiatry. 1987; 26:87-89. 41. Andrews JA, Lewinsohn PM. Suicidal attempts among older adolescents: Prevalence and co-occurrence with psychiatric disorders, J Am Acad Child Adolesc Psychiatry. 1992;31:655-662. 42. Garrison CZ, McKeown RE, Valois RF, et al. Aggression, substance use, and suicidal behaviors in high school students, Am J Public Health. 1993;83:179-184. 43. Weissman MM. The epidemiology of suicide attempts, Arch Gen Psychiatry. 1974;30:737-746.
1960 to 1971,
44. Schwab JJ, Warheit GJ, Holzer CE. Suicide ideation and behavior a general population, Dis Nerv System. 1972;33:745-748.
in
45. Bagley C, Ramsay R. Psychosocial correlates an urban population, Crisis. 1985;6:63-77.
in
of suicidal behaviors
21. Stanley M, Stanley B. Biochemical studies in suicide victims: Current findings and future implications, Suicide Life Threat Behav. 1989;19: 30-42.
46. Paykel ES, Myers JK, Lindenthal general population: A prevalence 460-469.
22. Arango V, Ernsberger P, Marzuk PM, et al. Autoradiographic demonstration of increased serotonin 5-HTr and B-adrenergic receptor binding sites in the brain of suicide victims, Arch Gen Psychiatry. 1989; 47:1038-1047.
47. Eaton WW, Holzer CE,, Von Korff M, et al. The design ofthe Epidemiologic Catchment Area surveys, Arch Gen Psychiatry. 1984;41:942948.
23. Brent DA, Perper JA, Allman CJ, et al. The presence and accessibility of firearms in the homes of adolescent suicides: A case-control study, JAMA. 1991;266:2989-2995. 24. Kellermann AL, Reay DT. Protection or peril? An anlysis of fuearmrelated deaths in the home, N Engl J Med. 1986;314:1557-1560. 25. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership, N Engl J Med. 1992;327:467-472.
JJ, et al. Suicidal feelings in the study, Br J Psychiatry. 1974;124:
48. Myers JK, Weissman MM, Tischler GL, et al. Six-month prevalence of psychiatric disorders in three communities, Arch Gen Psychiatry. 1984;41:959-967. 49. Blazer D, George LK, Landerman R, et al. Psychiatric disorders: rural/urban comparison, Arch Gen Psychiatry. 1985;42:651-656.
A
50. Burnam MA, Hough RL, Escobar JI. Six-month prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles, Arch Gen Psychiatry. 1987;44:687-694.
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5 1. Regier DA, Boyd JH, Rae DS, et al. One month prevalence of psychiatric disorders in five Epidemiological Catchment Area sites, Arch Gen Psychiatry. 1988;45:977-986. 52. Robins LN, Helzer JE, Croughan J, et al. NIMH Diagnostic Interview Schedule: Version III (May 1981). Rockville, MD: National Institute of Mental Health; 1981. 53. Robins LN, Helzer JE, Croughan J, et al. NIMH Diagnostic Interview Schedule: Its history, characteristics, and validity, Arch Gen Psychiatry. 1981;38:381-389. 54. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980. 55. Petronis KR, Samuels JF, Moscicki EK, et al. An epidemiologic
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57. Canetto SS. Gender Behav. 1992;22:80-97.
Sot Psychiatry
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58. Eaton WW, Kramer M, Anthony JC, et al. The incidence of specific DIS/DSM-III mental disorders: Data from the NIMH Epidemiologic Catchment Area program, Acta Psychiatr Stand. 1989;79:163-178. 59. Shapiro S, Skinner EA, Kessler LG, et al. Utilization of health and mental health services: Three Epidemiologic Catchment Area sites, Arch Gen Psychiatry. 1984;41:971-978. 60. Muehrer PR, Koretz DS. Issues in preventive Curr Direc Psycho1 Sci. 1992;1:109-112.
intervention
research,
ScD,
MPH
Attempted suicides occur primarily among women, while completed suicides occur primarily among men. Risk factors for both attempted and completed suicides include mental and addictive disorders, disrupted family environments, and precipitating events. This article presents an overview of findings on gender differences from epidemiologic studies of completed and attempted suicides, with a focus on suicide attempts among women, and discusses possible TeaSons for gender differences in suicidal behaviors. Ann Epidemiol 1994;4: 152-l 58. KEY WORDS:
Attempted suicide, gender, risk factors, suicide.
lumbia to 24.5/100,000
INTRODUCTION Completed
and attempted suicides are relatively rare events
that arise from a complex web of risk factors (1). They are extreme occurrences in a cluster of self-destructive behaviors that include less severe behaviors, ideation,
as well as increasingly
cluding suicidal ideation
such as casual suicidal
pathologic
behaviors,
with detailed plans,
in-
self-injury
without intent to die, failed suicide, and completed suicide. Attempted
and completed suicides share many underlying
characteristics,
but there also are important
tween them, including gender differences. understand
differences beIt is difficult to
attempted suicide, especially attempted suicide
among women, without understanding
the intricate prob-
lem of suicide itself. This article, therefore, from epidemiologic
studies of both
reviews findings
attempted
and com-
pleted suicides, with a primary focus on attempted suicides among women.
in Nevada (2). Traditionally,
suicide
rates have been highest in western states (l), with Vermont the single eastern exception
among the top ten.
Suicide rates differ by age, gender, and race. The 1990 age-adjusted
suicide rate for women was 4.5/100,000;
the
rate for men was 19/100,000 (2). The ratio of male to female suicide rates was thus 4.2. Consequently,
the scientific and
public focus has been on men and more recently on youth, because of their higher rates. The 1990 age-adjusted suicide rate for white women (4.8/ 100,000) was less than one-fourth (20.1/100,000) (2.4/100,000)
the rate for white men
(2). The age-adjusted rate for black women was less than one-fifth the rate for black men
(12.4/1000,000).
The distribution
of suicide rates for both
white and black women was fairly flat across age groups, with slightly higher rates for white women aged 35 to 59 years (Figure 1). The numbers of suicides for black women above age 50 were so low (< 20 in each 5-year age group) that age-specific rates were not estimated (2). In contrast to the similar age distributions
EPIDEMIOLOGY Incidence
OF COMPLETED
and Sociodemographic
SUICIDES
Characteristics
Suicide is the eighth leading cause of death in the United States. In 1990, the most recent year for which final mortality data are available, there were 30,906 suicide deaths, rep resenting 1.4% of the total number of deaths (2). Of these,
the age distributions
for black and white women,
for black and white men differed (see
Figure 1). Suicide rates for white men increased with age, while rates for black men peaked at ages 25 to 29, declined to age 65, and then peaked again at ages 70 to 74. These gender, race, and age-specific patterns also are evident when period and cohort effects are controlled
for (4).
6182 were committed by women. Homicide and suicide combined are the fourth leading cause of potential years of
Risk Factors
life lost (3). Suicide rates vary widely from state to state, and in 1990 ranged from 6.1/ 100,000 in the District of Co-
Systematic efforts to understand suicide began with Durkheim’s classic work in the late 19th century (5). With increasingly rigorous scientific work, including the application of multivariate
From the Prevention Research Branch, National Institute of Mental Health. Rockville. MD. Address reprint requests to: Eve K. MoScicki, ScD, MPH, Prevention Research Branch, National Institute of Mental Health, Room 10-85, 5600 Fishers Lane, Rockville, MD 20857. Received June 11, 1993; revised September 6, 1993. 0 1994b Elsevier Science Inc.
models in epidemiologic
studies of both com-
pleted and attempted suicide, has come increasing understanding of the interrelated risk factors for suicide. Although most research has been done in men, many risk factors
are believed
to be applicable
to both
men and
women. 1047.2797/94/$07.00
153
MoScicki GENDER DIFFERENCES IN SUICIDE
AEP Vol. 4, No. 2 March 1994: 152-158
Rates per 100,000 80 I
60
20
0 15-19 10-14
25-29
35-39
20-24
30-34
45-49 40-44
5-Year
55-59 50-54
65-69
65t
75-79
60-64
70-74
60-84
Age Groups
FIGURE 1. Suicide rates per 100,000 population by gender, race, and S-year age groups, United States, 1990. Rates were not calculated when based on fewer than 20 deaths. (Unpublished data from the National Center for Health Statistics.)
Suicide is a complex behavior with multiple risk factors, which fall into two broad categories-distal
and proximal.
Distal risk factors represent the foundation
on which events
Postmortem
studies have found reduced serotonergic
ity in the brains of suicide victims (20, 21), although not clear whether the effect of serotonin
associated with suicidal behavior are built, but do not lead
behaviors
directly to attempted
cific psychiatric
include underlying
or completed
psychiatric,
suicide. Distal factors
biologic,
(6). The strongest observed associations
and familial risks are for psychiatric
activit is
levels on suicidal
is direct, or whether it is mediated through spedisorders (18, 22).
Proximal risk factors are precipitating
circumstances
sociated with the suicide event itself. In combination
aswith
disorders (1, 6). More than 90% of completed suicides are
strong distal risk factors such as mental or addictive disor-
associated with mental or addictive disorders (7-9), the most
ders and a disrupted familial environment,
common of which are depression, personality disorders, and
factors contribute
alcohol abuse (7-10).
for suicide. Such “triggering” events are likely to differ with
Comorbid
occurrence
of more than
one psychiatric disorder, or comorbid mental and drug use disorders have been found frequently
(7, 8, 11, 12), sug-
proximal
risk
to the necessary and sufficient conditions
age, gender, ethnicity,
and other sociodemographic
factors.
The presence of a firearm in the home has been shown
gesting that completed suicide is associated with more severe
to be a major situational
forms of mental illness. It is likely that distal risk factors
Firearms account for nearly 60% of all suicide deaths; it is
are necessary, but not sufficient, for suicide to occur (7). Other distal risk factors include a family history of suicide and/or mental or addictive disorders (13, 14), and a disrupted family environment vorce, widowhood,
as defined by separation,
di-
or family violence. Suicide rates for di-
vorced and widowed women and men are higher than rates
factor in suicide deaths (23-25).
the method of choice for both men and women, followed by drugs and medicaments’
for women and hanging
for
men. Other alcohol,
proximal
risk factors include intoxication
with
crack cocaine, or other drugs (26, 27); recent, se-
vere, stressful life events such as the death of a spouse
for married persons (1, 15). In the case of divorce or separa-
(among young people, the sudden death of a friend or ac-
tion, it is not clear whether the disruption of the marriage
quaintance);
itself leads to suicide, or whether persons who are more likely to be suicidal also are more likely to be in an unstable
to the suicidal behavior of others (29); economic problems (28); finding oneself in jail (28, 30); and being diagnosed
marriage. A family environment
that includes violence in
with acquired
interpersonal
loss or rejection
immunodeficiency
syndrome
(28); exposure
(AIDS)
(3 1).
the form of physical and sexual abuse also may contribute to suicide risk (16, 17). In addition, there is consistent
evi-
dence that biologic risk factors may be associated with suicide and suicidal behavior
and with impulsivity (18, 19).
’“Medicaments” is the term used by the National Center for Health Statistics to classify self-inflicted deaths from medicinal agents.
154
Mdcicki GENDER DIFFERENCES IN SUICIDE
AEP Vol. 4, No. 2 March 1994: 152-158
One precipitating factor that has long been thought to con-
of the attempters, and the most common method of attempt
tribute to suicide, particularly in older adults, is the presence
was self-medication,
of a chronic
attempts (43).
or terminal
illness. Physical illness, however,
has not been shown to be an independent suicide outside the context psychopathology
accounting for 70 to 90% of all reported
risk factor for
A recent study based on surveillance of Oregon hospitals
of clinical depression or other
in 1988 reported an annual attempted suicide rate of 214/
(32).
100,000 for children (36). Eighty-four
and adolescents
aged 10 to 17 years
percent of the attempters
were females.
The most common method used by suicide attempters was EPIDEMIOLOGY
OF ATTEMPTED
drug overdose,
SUICIDE
which accounted
for 76% of all reported
attempts. The ratio of attempted to completed suicide rates
between Completed and Attempted Suicides
was estimated at 47. No data were collected for adults.
Although
Community
Differences
completed and attempted suicides have common
characteristics,
there also are important differences, limiting
the generalizability of findings between populations of completers and attempters.
One important
difference
is that
nearly 80% of suicide completers are men, while the majority of attempters are women. Another
is that not all attempters
injure themselves with the intent to die. Even when there is a strong intent to die, not all attempters injure themselves severely enough to cause death (33). Numerous
studies have shown attempted
suicide to be
a strong risk factor for completed suicide (7, 10,34). It generally is not considered
to be a clinically reliable predictor,
however, since it will generate a large proportion
of false-
positives, especially among younger age groups (35-37). One difficulty with predicting completed suicide based on a reported or observed attempt is associated with the measurement of severity of the attempt and the amount of suicidal intent associated with it (33, 38, 39). Self-inflicted
injuries
that are labeled as attempted suicides range widely in severity from a “cry for help” without intent to die to a genuine failed suicide. Some progress has been made in this area with the recent use of medical lethality as an index of severity, which appears to be an adequate way of distinguishing between most failed suicides and cries for help (33, 40-42). However it is defined (or not, in many studies), attempted suicide is an extreme form of behavior
and an expression
of distress that in and of itself merits study.
Studies
Lifetime data from the few community been conducted demonstrate on hospital data (44-46).
There are no national, population-based
men; other studies (45,46) did not report separate estimates of attempts by gender, but did note that risk was higher in women.
All of these reports suggested that attempted
suicide occurred more frequently
suicide. Weissman (43) reviewed English-language studies on attempted suicides between 1960 and 197 1, nearly all of
among persons with high
levels of psychiatric symptoms or with psychiatric diagnoses, especially depression (44-46). The best available prevalence
data on suicide attempts
among adult women in the general population
come from
the National Institute of Mental Health (NIMH) Epidemiologic Catchment
Area Study (ECA) (38). Detailed descrip-
tions of the methodology elsewhere (38,47-5
and initial findings have appeared
l), and can be summarized here. Briefly,
the purpose of this five-site study was to measure selected psychiatric
disorders and sociodemographic
the population.
risk factors in
Data were collected from 18,571 adults 18
years and older at two points in time, 1 year apart. Information on psychiatric symptoms was obtained using the Diagnostic Interview Schedule (DIS) (52,53), psychiatric
a highly structured
interview designed to be administered
by lay
interviewers. Diagnoses of psychiatric disorders were generated by computer algorithm according to standardized criteria established Psychiatric
data on attempted
Schwab and colleagues (44) found
lifetime attempt rates to be 4.0% for women and 1.2% for
in the Diagnostic
Mental Disorders,
Prevalence
studies that have
findings similar to those based
and Statistical
third edition (DSM-III)
Association
Manual of
of the American
(54).
The DIS included questions on thoughts of death, desire to die, suicidal ideation,
and suicide attempts.
rates were weighted to be representative
Prevalence
of the US popula-
which reported on data from hospital admissions. As might
tion. Initial analyses of these data indicated
be expected, there was a great deal of variation among stud-
prevalence
ies in completeness of coverage and data quality. Crude annual rates of attempted suicide ranged from 43/100,000
compared
in New Delhi to 730/100,000 in London, Ontario. With the exception of the New Delhi study, all reported a higher
attempted suicide was a lifetime diagnosis of any psychiatric
frequency of attempts by women than by men, with gender ratios ranging from 1.3 to 3.0. Weissman found that persons less than 30 years old frequently accounted for 50% or more
of attempted
that lifetime
suicide among women was 4.2%
with 1.5% among men, with an adjusted odds
ratio of 3.3 (38). The strongest independent
risk factor for
disorder, with an odds ratio of 8.4 (38). In order to determine whether the occurrence
of at-
tempted suicide was associated with severity of psychopathology, an index of severity was constructed based on the
155
MoScicki GENDER DIFFERENCES IN SUICIDE
AEP Vol. 4, No. 2 March 1994: 152-158
number of clinical diagnoses. The sample was grouped into
black males = 0.8%), there were no statistically significant
persons with no psychiatric
more than one diagnosis, and compared on the proportion
differences between race and gender groups (42). Significantly increased risk for all suicide attempts was found to
diagnosis,
one diagnosis,
and
of suicide attempts, stratified by gender. Women had greater
be associated with aggressive behaviors,
rates of attempted suicide regardless of the number of diag-
hol use, and illicit drug use. Odds ratios increased in magni-
noses. In both men and women, persons with more than
tude for attempts requiring medical care, with the highest
one diagnosis had the highest rates of attempted
suicide
cigarette use, alco-
odds ratios associated with intravenous
drugs and cocaine
cantly by gender. Odds ratios were 3.8 for women with one
use (42). Andrews and Lewinsohn (41) conducted a detailed study
lifetime diagnosis (95% confidence
of psychiatric disorders in a representative cohort (n = 17 10)
(men = 7.3%; women = 21.8%). Risk did not differ signifiinterval (CI), 2.9 to 4.9)
and 17.3 for women with more than one lifetime diagnosis
of high school students in five communities
(95% CI, 13.4 to 22.3), compared with women who had no
Oregon. Attempted suicides were rated for medical lethality
psychiatric
diagnosis.
Odds ratios were 4.1 for men with
in west central
and intent to die. The lifetime rate of attempted suicide at
one lifetime diagnosis (95% CI, 2.2 to 7.7) and 18.7 for men
baseline was 7.1%; the rate for females, lO.l%,
with more than one lifetime diagnosis
10.7 to
cantly greater than the rate for males, 3.8%. Thirteen (0.7%)
diag-
of the attempts reported by 12 1 adolescents were considered
32.6), compared
(95% CI,
with men who had no psychiatric
medically lethal,
nosis.
was signifi-
and six (0.35%)
were given the highest
rating on intent to die. Lethality
and intent were signifi-
cantly correlated (0.67). There were no gender differences
Recent Attempted Suicides in the Community
in lethality. At follow-up, 2.2% of females and 1.1% of males
Lifetime data are subject to recall bias, since they are heavily
reported having attempted suicide in the 12-month period
dependent
prior to interview, but the gender differences were not statis-
on a person’s ability to remember
important
events. Since women are generally considered to be better
tically significant.
reporters of health history than are men, as well as more
reported for the follow-up period. One of the most striking
frequent
findings of this study was the extremely
users of health services, the higher lifetime rates
of attempted suicide among women may not represent patterns of recently attempted
suicide in the population.
Later analyses of the ECA data addressed this potential bias by examining
l-year prevalence of attempted suicide.
Medical
lethality
and intent
were not
high proportion
of attempters who met criteria for at least one psychiatric diagnosis at both baseline and follow-up. Eighty percent of attempters
at baseline and nearly 100% at follow-up were
diagnosed with major depressive episode, alcohol and other
The prevalence of recent attempted suicide in the year prior
drug use disorders, and/or a disruptive behavior
to baseline was 22/100,000.
The prevalence was 19/100,000
There were no gender differences in the proportion
in the year prior to follow-up (55). There were no significant
tempters diagnosed with any of the disorders (41).
disorder. of at-
gender or age differences for either prevalence period. The estimated overall ratio of attempts to completions When
stratified by gender,
however,
was 18.
the estimated
ratio
was 8 for men and 59 for women, reflecting the much lower rates of completed suicide for women. Multivariable
condi-
tional logistic regression analyses showed that the most pow-
GENDER DIFFERENCES BEHAVIORS
IN SUICIDAL
The gender differences between rates of completed suicide
erful risk factors for recent attempts were recent major de-
and lifetime rates of attempted
pressive episode, recent alcohol abuse or dependence,
significant gender differences in recent attempted suicides,
any
suicides, and the lack of
recent cocaine use, and divorced or separated marital status
present an intriguing epidemiologic
(55). These risk factors for attempted suicide are identical to
Several plausible explanations
problem.
have been proposed, some
the distal risk factors most frequently reported for completed
more plausible than others. First, there is the lethality expla-
suicides.
nation; that is, gender differences between
Two studies of suicidal behaviors in community
popula-
completions
can be explained
tions of adolescents also failed to find gender differences for
method.
medically lethal attempts (4 1, 42). Garrison
commit suicidal acts in equal proportions,
(42) analyzed data from the Youth in South Carolina.
more suicide behaviors
in the past 12 months although
Risk Behavior
Survey
They found that high school females
reported significantly However,
and associates
of all kinds
than did males, regardless of race.
the proportion
of attempts
requiring
This explanation
attempts
by the choice
and
of suicide
assumes that men and women and that all sui-
cidal acts are intended to result in death. Since men choose more lethal methods, however, their suicidal acts are more likely to result in death. The lethality explanation is frequently encountered in the literature (e.g., [36]). It does not take into account intent to die, however, and disregards
medical treatment was slightly higher among females (white
the role of self-injury as a signal for help. It also does not
females = 1.9%, black females = 2.3%, white males = 1.2%,
offer reasons as to why men use more lethal methods, partic-
156
MoScicki GENDER DIFFERENCES
AEP Vol. 4, No. 2 March 2994: 152-158
IN SUICIDE
ularly in light of the fact that a firearm, an especially lethal
but simplistic prevention
means, is the method of choice for both men and women.
tiveness has been demonstrated
A second explanation time suicide attempts
for the greater frequency
reported
by women
efforts. Neither efficacy nor effecfor any existing suicide pre-
of life-
vention program. Indeed, the ability to predict which indi-
is recall bias.
viduals will die by suicide continues to be marginal (IO, 35).
Women are known to be better reporters of health history,
The preponderance
of powerful distal risk factors, espe-
and since most suicide attempt data from community studies
cially mental and addictive disorders, implies that a simplis-
are self-reported,
tic focus only on proximal or precipitating
this may explain in part the higher rates
among women.
risk factors is
unlikely to result in a substantial reduction of either suicide
A third explanation
to account
for differential
gender
attempts
or deaths.
Distal risk factors
also must be ad-
rates may be gender differences in socialization. According
dressed. Preventive
to this explanation,
intensive, and long-term as the behaviors they are intended
there are gender differences in culturally
interventions
need to be as complex,
acceptable self-destructive behaviors (56). Men are less likely
to prevent in order to have lasting effects over time (60).
to attempt suicide because attempts are considered
Ideally, prevention
“femi-
nine.” At the same time, men are more likely to engage in “masculine” self-destructive
behaviors
such as alcohol and
programs
risk factors simultaneously.
should address an array of
For example, suicide prevention
efforts need to be embedded in programs that address distal
other drug abuse, or use more aggressive and lethal methods
risk factors such as mental health and substance
of self-destruction
well as proximal
(57). This explanation
ported by the over-representation
is indirectly sup-
of men among chronic
abuse, as
risk factors such as responsible
firearm
ownership. Such programs are admittedly difficult to imple-
liver disease and cirrhosis deaths (2), by the large proportion
ment and monitor.
of men completing
and tested, however, the best hopes for prevention of suicide
suicides who were found to be intoxi-
cated at the time of death (7,8,26),
and by the large propor-
tion of men who commit suicide by means of firearms (37). The increased prevalence
Until such programs can be designed
and suicidal behaviors treatment
are identification
of mental and substance
and appropriate
abuse disorders.
of suicide with age among men
may indicate that women, especially older women, may be more willing and flexible in adapting to changing life situations than are men as a result of a lifetime of socialization and developmental
experiences.
less likely to respond
They
to severely
therefore
stressful
may be
life events,
such as the death of a spouse, with lethal self-destructive behavior (57). A fourth explanation
for the gender differences may be
found in the differential rates of depression and alcohol abuse. Women have higher incidence and prevalence rates of depression,
higher rates of recurrent
treatment
episodes,
and higher
rates, than do men (51, 58, 59). Men,
other hand, have higher rates of alcoholism abuse (51, 58). Clinical
depression
on the
and alcohol
is strongly
associated
with both completed and attempted suicides, and the higher lifetime rates of attempted suicide may be explained by overall higher rates of clinical depression among women. This explanation of completed
is not consistent with the higher observed rates suicide in men, however.
It is possible that
the lower rates of completed suicide among women may be explained in part by higher treatment
rates for depression.
That is, women in a major depressive episode may be as suicidal as men, but successful treatment for depression attenuates its severity and prevents suicide.
IMPLICATIONS
FOR
IMPLICATIONS
FOR
RESEARCH
The problem of gender differences
in suicide complicates
an already complex issue, and offers an interesting scientific challenge to epidemiologists.
The explanations
for gender
differences in suicide that have appeared in the literature, summarized above, can be examined logic hypotheses.
as testable epidemio-
In order to better understand
the gender
differences in completed and attempted suicides, however, it is first necessary to understand differential gender distributions
the reasons behind the
in the primary risk factors
for suicide, mental and addictive disorders. For example, although it is clear that severity and comorbidity
of psychi-
atric disorders are associated with both attempted and completed suicide, is the differential gender distribution chopathology Alternatively,
influenced
by severity,
and
in psy
if so, how?
how is severity of disorder mediated by gen-
der? How do distal and proximal risk factors interact with each other and with gender to produce attempted or completed suicide in women and men? Are there gender-specific biologic or environmental factors that protect women against certain psychiatric them from completed
disorders that also may protect
suicide? These and other questions
need to be examined in order to make meaningful progress in efforts to prevent attempted and completed suicides.
PREVENTION
Despite its complexity, a great deal has been learned about suicide and suicidal behaviors. Unfortunately, the scientific approach has not been widely applied to most well-meaning
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