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Suicide mortality in adolescents and young adults, 1980-1999
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RESP Informations
ARTICLE ORIGINAL Suicide mortality in adolescents and young adults, 1980-1999 Over the last two decades, overall mortality from suicide in the European Union, as well as in several Central and Eastern European countries (with the major exception of Russia and other countries of the former Soviet Union) has fallen appreciably, particularly in women. Likewise, appreciable declines in certified mortality from suicide were observed for women in the USA and for both sexes in Japan [1-3]. Rates have however increased in other countries, such as Cuba, Australia, New Zealand and some European countries (Iceland, Ireland, Italy, Spain), but, in spite of mixed trends, the global picture of suicide mortality has been relatively favourable across countries providing data to the WHO database [2]. Overall age-standardized suicide rates, however, may conceal different trends at different ages. These are not easily detectable by cohort analysis, since age effects may have major relevance on suicide rates [4]. Over recent years, in particular, upward trends in mortality from suicide in the young have been reported from several countries, including the UK, Ireland, Spain and Australia [5-7]. We have therefore updated trends in death certification rates from suicide over the last two decades in adolescent and young adults in 47 countries worldwide providing data to the WHO database [2].
METHODS Official death certification data for suicide were abstracted from the WHO database (http://www3.who.int/whosis/menu.cfm) over the period 1965-99, whenever available. Estimates of the resident population, generally based on official censuses, were based on the same WHO database. Although this database contains some data on mortality or population for a large number of countries, it was possible to obtain a meaningful and structured format (i.e., age-specific data for each sex, and for subsequent calendar years up to the late 1990’s) only for 47 of them. These included a total of 32 countries in Europe, 2 in North America, 5 in Latin America and the Caribbean, 1 in Africa, 5 in Asia, and 2 in Oceania. Data were missing for one or more calendar years for a few countries (as indicated in tables I and II). All countries providing meaningful data to analyze trends in suicide mortality over the calendar period considered were included, in the absence of any a priori exclusion. The European Union (EU) was defined as including the 15 member countries in 1999. Countries of the former Soviet Union included all those providing data to the WHO database in 1999. Countries may differ in ascertainment and classification criteria. In the 1990s, in fact, most countries utilized the Ninth Revision [8] of the International Classification of Diseases (ICD), but some still used the Eighth Revision [9] and some adopted the Tenth Revision [10] from 1995 onwards. Since differences between various Revisions were minor, suicide deaths were re-coded for all countries according to the Ninth Revision of the ICD (E 950-9). To improve
comparability across countries, probable suicides (ICD-9 E 980-9) were not included in the present analysis. From the matrices of certified deaths and resident populations in five-year age groups, age-specific rates for each calendar period were computed. Age-standardized rates at 15 to 24 and at 25 to 34 years were subsequently derived, on the basis of the world standard population.
RESULTS Table I gives age-standardized death certification rates from suicide at age 15 to 24 in various countries providing data to the WHO database. Figure 1 gives the corresponding trends in five selected major geographic areas (the EU, selected Eastern European countries, Russia, the USA and Japan). In the EU as a whole, suicide mortality declined by 6.6% in men and 20.8% in women. Among major Western European countries, suicide rates decreased in France and Germany, but increased in Italy, Spain and the UK. Consequently, they tended to level between 7 and 14/ 100,000 males, and between 2 and 4/100,000 females. Rates for young men were over 20/100,000 in a few other Western European countries, including Belgium, Ireland, Norway, Switzerland and mostly Finland (with a rate of 34.6/100,000 men in 1995-99), and even higher in Central and Eastern Europe, with rates around 25-27/100,000 men (but declining) in Hungary and Poland, of 34 to 48/100,000 in Estonia, Latvia and Lithuania, up to 52.8/ 100,000 in the Russian Federation. Russian suicide rates at age 15 to 24 showed an over 100% rise over the last two decades. For adolescent and young women, rates were around or over 6/ 100,000 in Belgium, Finland or Norway, up to 9/100,000 in the Russian Federation, again with appreciable and systematic upward trends over the last two decades. For adolescent and young men, suicide rates were around 10/100,000 in most South American countries providing data, but trends were upwards over the last two decades. Suicide rates were higher (around 20/ 100,000) in the USA and Canada, in the absence however of major trends over time. In 1995-99, Cuba had the highest suicide rates in women aged 15 to 24 worldwide (15.3/100.000 as compared to 13.3 in men). While rates in Israel, Hong Kong and Japan were similar to those in Western Europe, extremely high rates were observed in Australia (24.7/100,000 men aged 15 to 24, 5.7/100,000 women) and New Zealand (38.8 and 12.8 respectively), with substantial upward trends over time, i.e. over 100% during the last two decades in New Zealand. Table I and figure 2 give corresponding values at age 25 to 34 years. In the EU as a whole, the fall was 10.9% in men and 31.6% in women. For men, the range of variation was greater across major Western European countries, i.e. between 10.9/100,000 in Italy and 28.0 in France in the late 1990’s. Also trends over time were heterogeneous, with declines in France and Germany, but upward trends in Italy, the UK and, mostly, Spain, which however started from extremely low rates in the 1980’s. Among men, the lowest rates were in Portugal (7.4/100,000), Greece and Italy, and the highest ones in Latvia (62.7/100,000), Lithuania (74.5) and the Russian Federation (82.5), with appreciable upward trends in all these countries. Across Europe in women aged 25 to 34, only Russia (10.6) and Finland (12.9) had rates over 10/100,000, and most rates were downwards. Suicide rates at age 25 to 34 were around
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Table I. — Trends in 15-24 year age-standardized (world population) death certification rates for suicide in Europe and other selected areas of the world, 1980-1999*. MALES COUNTRY
1980-84*
1990-94
FEMALES
1995-99*
1980-84*
1990-94
1995-99*
% CHANGE 95-99 vs 80-84
% CHANGE 95-99 vs 80-84
EUROPE AUSTRIA BELARUS (85-89) BELGIUM (95-96) BULGARIA CROATIA (85) CZECH REPUBLIC (86-89) DENMARK (95-98) ESTONIA (85-89) FINLAND FRANCE GERMANY** GREECE HUNGARY ICELAND (95-97) IRELAND ITALY LATVIA (85-89) LITHUANIA (85-89) LUXEMBOURG THE NETHERLANDS NORWAY POLAND (95-96,99) PORTUGAL ROMANIA (85-89) RUSSIAN FED. (85-89) SLOVAKIA (92-94) SLOVENIA (85-89) SPAIN SWEDEN SWITZERLAND UKRAINE (85-89) UNITED KINGDOM EUROPEAN UNION (95-98) AMERICAS ARGENTINA (95-96) CHILE (90-94) COSTA RICA (95) CUBA (75-79/94/95-96) MEXICO (95) CANADA (95-98) UNITED STATES
29.9 16.6 15.5 10.7 17.0 14.4 17.0 26.9 33.6 15.3 19.8 3.7 27.6 23.0 9.7 5.0 21.6 23.8 17.7 6.8 21.1 17.7 8.0 10.2 25.2
22.0 33.1 20.8 13.8 21.4 15.7 12.2 34.5 34.6 13.1 12.6 3.8 17.4 17.2 28.2 7.2 34.0 48.1 18.0 9.0 22.3 18.4 4.0 10.5 52.8 12.3 28.4 7.8 12.0 22.1 26.7 10.2 10.8
–26.5 99.9 34.1 28.9 25.5 8.6 –28.2 28.1 3.2 –14.5 –36.6 2.4 –37.0 –25.5 191.9 44.2 57.9 102.5 1.6 31.5 5.7 4.3 –50.6 2.8 109.8
7.9 3.8 4.8 5.6 5.2 4.5 5.7 7.3 6.0 4.9 5.9 1.7 8.6 2.7 2.7 1.7 5.9 6.0 5.2 3.7 4.0 4.1 4.9 4.1 5.7
26.0 5.0 15.3 34.4 14.7 7.1 11.6
23.2 23.0 17.1 14.1 21.6 15.3 11.9 28.8 40.4 14.7 12.8 4.7 21.0 35.0 18.6 6.3 30.8 32.0 21.9 8.7 23.5 16.7 5.8 9.7 36.5 13.6 27.4 7.0 12.9 24.2 19.3 11.2 11.1
9.3 55.3 –21.6 –35.7 81.3 43.5 –6.6
6.1 11.0 8.8 8.3 4.0 26.2 19.3
7.2 9.5 8.7 13.0 5.8 24.7 21.9
8.9
46.0
11.9 13.3 7.5 22.9 19.3
35.6 59.6 89.4 –12.6 0.1
18.6 10.5 10.0 12.7 9.0
13.5 73.9 72.8 –15.9 26.0
24.7 38.8
38.0 113.0
AFRICA, ASIA, AUSTRALIA AND OCEANIA MAURITIUS (85-89) 16.4 HONG KONG (95-96) 6.0 ISRAËL (95-98) 5.8 JAPAN 15.1 SINGAPORE 7.1 THAILAND (85-87/94) 11.5 AUSTRALIA 17.9 NEW ZEALAND (95-98) 18.2
17.8 8.2 10.6 9.9 10.1 5.3 25.3 38.5
9.4 1.3 5.7 9.0 4.1 2.2 3.7
5.8 4.4 4.2 4.6 5.1 4.0 3.3 8.4 7.3 4.3 3.5 0.7 6.0 3.1 3.0 1.7 6.1 7.6 2.7 3.4 5.3 2.7 2.2 3.1 7.5 2.4 6.5 1.7 5.3 5.5 4.6 2.1 2.9
4.1 5.7 5.8 4.4 5.1 3.2 3.2 6.5 7.1 4.0 3.4 0.7 3.7 4.9 4.7 1.7 6.3 7.8 4.3 3.8 6.6 2.8 1.5 2.6 9.2 1.7 6.0 2.0 5.5 5.7 4.9 2.4 2.9
–35.9 47.0 –4.0 –36.5 17.6 11.5 –20.8
3.9 3.2 3.4 19.6 1.5 4.6 4.2
3.0 1.9 2.9 15.4 1.4 5.0 3.8
3.3
–14.2
4.0 15.3 2.0 4.8 3.4
17.5 –22.2 37.0 4.5 –18.7
16.3 5.0 2.4 6.8 8.7 9.5 3.9 4.9
16.2 6.3 2.2 4.6 6.6 4.3 4.8 6.7
11.5 6.3 2.5 5.9 5.8
–29.5 26.0 5.9 –14.0 -33.1
5.7 12.8
46.8 160.0
* First and most recent period available, 1980-84 and 1995-99 respectively, unless otherwise mentioned in parenthesis. ** Including Federal and Democratic Republic of Germany before 1990.
–48.0 50.8 21.8 –20.9 3.3 –29.6 –44.6 –11.0 17.7 –19.1 –42.8 –57.8 –56.5 86.0 72.8 0.6 7.2 29.5 –16.1 3.0 65.2 –32.1 –68.9 –38.3 62.0
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Table II. — Trends in 25-34 year age-standardized (world population) death certification rates for suicide in Europe and other selected areas of the world, 1980-1999*. MALES COUNTRY
FEMALES
1980-84* 1990-94 1995-99*
1980-84* 1990-94 1995-99* % CHANGE 95-99 vs 80-84
% CHANGE 95-99 vs 80-84
EUROPE AUSTRIA BELARUS (85-89) BELGIUM (95-96) BULGARIA CROATIA (85) CZECH REPUBLIC (86-89) DENMARK (95-98) ESTONIA (85-89) FINLAND FRANCE GERMANY** GREECE HUNGARY ICELAND (95-97) IRELAND ITALY LATVIA (85-89) LITHUANIA (85-89) LUXEMBOURG THE NETHERLANDS NORWAY POLAND (95-96,99) PORTUGAL ROMANIA (85-89) RUSSIAN FED. (85-89) SLOVAKIA (92-94) SLOVENIA (85-89) SPAIN SWEDEN SWITZERLAND UKRAINE (85-89) UNITED KINGDOM EUROPEAN UNION (95-98) AMERICAS ARGENTINA (95-96) CHILE (90-94) COSTA RICA (95) CUBA (75-79/94/95-96) MEXICO (95) CANADA (95-98) UNITED STATES
38.6 39.4 32.3 14.4 25.4 27.9 38.4 47.2 53.7 30.7 29.0 5.9 57.5 22.8 15.0 8.7 43.7 55.4 33.9 15.9 22.0 34.0 11.1 19.6 51.0
27.2 70.0 30.3 16.2 23.0 22.9 21.1 53.9 49.5 28.0 18.8 7.7 38.0 33.0 32.6 10.9 62.7 74.5 21.4 15.7 22.4 25.2 7.4 19.7 82.5 20.3 40.7 12.4 19.2 26.3 52.4 18.3 18.2
–29.4 77.5 –6.0 12.2 –9.5 –17.9 –45.2 14.2 –7.9 –8.7 –35.0 30.2 –33.9 44.9 117.3 25.5 43.5 34.5 –36.9 –1.2 2.1 –25.9 –32.9 0.5 61.8
10.0 5.6 12.3 5.1 8.3 7.6 15.9 10.2 12.0 10.2 10.0 2.1 15.8 3.4 4.4 3.1 8.6 9.8 9.8 8.9 7.0 5.5 4.6 4.1 7.0
48.2 6.8 31.6 39.1 36.5 14.2 20.4
29.8 49.0 29.9 18.1 31.2 24.6 24.9 56.7 61.3 31.8 21.4 5.8 51.3 26.5 27.7 10.8 64.7 63.7 22.0 15.6 25.8 29.1 13.6 17.7 68.9 23.1 44.6 11.5 23.3 33.1 41.6 17.3 19.9
10.4 1.8 12.0 14.1 4.9 4.3 6.9
7.9 6.2 9.4 5.6 6.8 7.0 7.2 8.7 11.9 8.9 5.9 1.4 10.6 3.0 5.4 2.9 9.1 8.3 6.2 7.1 7.1 4.2 3.6 3.9 8.8 3.5 8.2 2.7 9.6 8.8 5.7 3.9 5.4
4.1 8.1 9.5 5.8 5.0 3.7 4.6 5.0 12.0 8.0 4.9 1.4 7.5 5.2 5.3 2.8 8.5 9.1 8.8 6.5 6.7 3.1 1.8 3.1 10.6 2.5 8.4 2.7 6.6 7.2 6.9 3.8 4.7
–15.6 83.3 –39.2 –32.8 43.6 28.9 –10.9
8.9 13.0 15.4 11.9 4.6 29.5 25.3
9.0 13.8 11.8 23.2 7.0 28.2 24.9
9.2
3.6
14.9 23.3 9.2 25.0 23.8
–3.4 96.5 101.1 –15.4 –6.1
–19.0 47.0 –45.5 –48.8 40.2 –13.2 –31.6
3.5 2.2 2.6 11.0 1.1 7.8 6.8
3.2 2.2 1.9 14.7 1.0 6.1 5.2
2.4
–31.6
2.3 12.9 1.2 5.7 4.9
–9.7 17.4 3.5 –26.8 –27.7
13.1 9.9 3.8 8.3 9.1 2.9 6.5
11.3 7.9 2.1 9.8 7.9
188.5 –9.0 –51.9 –12.3 –16.4
7.3
9.8
7.5
8.0
13.7
AFRICA, ASIA, AUSTRALIA AND OCEANIA MAURITIUS (85-89) 9.6 HONG KONG (95-96) 13.5 ISRAËL (95-98) 10.2 JAPAN 25.4 SINGAPORE 13.8 THAILAND (85-87/94) 10.9 AUSTRALIA 23.7
31.0 14.2 12.6 18.6 14.3 8.4 29.5
33.9 16.3 10.6 23.1 13.6
254.8 20.8 3.2 –9.0 –1.3
35.4
49.5
3.9 8.6 4.4 11.2 9.4 5.9 6.6
NEW ZEALAND (95-98)
32.7
41.0
97.4
7.0
20.8
* First and most recent period available, 1980-84 and 1995-99 respectively, unless otherwise mentioned in parenthesis. ** Including Federal and Democratic Republic of Germany before 1990.
–29.1 42.9 –23.2 13.7 –40.0 –51.8 –70.9 –50.8 –0.2 –21.4 –50.5 –32.5 –52.8 –52.8 21.4 –9.6 –1.3 –7.3 –10.4 –27.1 –4.3 –43.2 –60.5 –24.3 51.4
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FIG. 1. — Trends in age-adjusted (world standard) death certification rates per 100,000 males (a) and females (b) aged 15-24 from suicide in European Union, six Eastern European countries (Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovakia), Russian Federation (period 1985-99), United States, and Japan, 1965-99.
20/100,000 men and 5/100,000 women in the USA, with a slight downward trend over time. As for the youngest age group, the highest rate registered worldwide at age 25 to 34 for women was in Cuba (12.9/100,000), as compared to 23.3 in men. Over recent calendar years, suicide rates at age 25 to 34 were 23.1/100,000 men and 9.8/100,000 women in Japan, with appreciable downward trends over time. In contrast, these were 35.4/100,000 men in Australia and 41.0 in New Zealand, with rises by about 50 and 100%, respectively, over the last two decades for males, but in the absence of clear trends in women over the same calendar period.
DISCUSSION The main observation from the present, systematic re-analysis of worldwide trends in suicide mortality in adolescent and young adults is the heterogeneous patterns of trends across various
countries and areas of the world over the last two decades. Thus, the overall favourable pattern of mortality from suicide at all ages registered over the last two decades in most Western countries (and Japan) [2, 3] was not reproduced in the young and even more in adolescents, mainly for men. For young women, suicide rates were favourable in the EU as a whole and Japan, but less consistent in other major areas of the world. Some of the apparent geographic variations, as well as some of the trends over time, may be due to changes in certification and coding of suicide deaths, since quality of mortality data on suicides worldwide is known to be variable [11]. These changes, partly related to modified socio-cultural attitudes towards suicide, may therefore explain some upward trends in selected countries, including Ireland [1, 12, 13]. In any case, the present analyses indicate that due caution is required for making general inference from trends observed in the young in any single country.
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FIG. 2. — Trends in age-adjusted (world standard) death certification rates per 100,000 males (a) and females (b) aged 25-34 from suicide in European Union, six Eastern European countries (Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovakia), Russian Federation (period 1985-99), United States, and Japan, 1965-99..
On a cohort of death basis [4, 5, 7] some of the substantial rises in suicide rates in adolescent and the young observed in countries like Ireland, Russia, and other countries of the former Soviet Union, Cuba, Australia, or New Zealand could suggest that such massive upward trends can be maintained when the same cohorts will enter middle age. However, understanding age and cohort components in suicide rates is more complex than for chronic diseases [4], and consequently any long-term projection remains undefined. A limitation of the present study is its restriction to the WHO mortality database, including valid suicide mortality data over the last two decades only for 47 of the 191 member countries [2]. These do not include major countries like India, Sri Lanka or China, where suicide accounts for a substantial proportion of all deaths, particularly in the young [14-16]. Despite persisting high rates, suicide trends in the young over the last two decades have been favourable in Hungary, Poland
and other major former non-market economy Central European countries, reflecting underspread social improvements in these areas of the continent [17]. In contrast, on a public health level, the most worrisome aspect of the present analysis is given by extremely high rate of suicide among the young in Russia [18-21]. Russian suicide rate for males were over 50/100,000 at age 15 to 24, and over 80 and age 25 to 34, and similar values were observed in other countries of the former Soviet Union. This reflects social deprivation over the last two decades [22-24], as well as widespread alcohol abuse in these countries [21]. It is likely, on the other hand, that use of antidepressants [25] had a smaller favourable impact on suicide rates in the young, as compared to middle age and elderly populations. Whatever the underlying major reasons for the current suicide epidemic in Russia [26], this calls for urgent intervention to control an important and avoidable cause of death in the young.
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ACKNOWLEDGEMENTS . — This study has been made possible by a core grant of the Swiss League against Cancer. Support was also received from the Italian Association for Cancer Research.
F. LEVI1, 2, F. LUCCHINI1, E. NEGRI3, C. LA VECCHIA1, 3, 4 1. Cancer Epidemiology Unit, University Institute of Social and Preventive Medicine, Bugnon 17, CH-1005 Lausanne, Switzerland. 2. Cancer Registry of Vaud, University Institute of Social and Preventive Medicine, CHUV Falaises 1, CH-1011 Lausanne, Switzerland. 3. Laboratory of Epidemiology, “Mario Negri” Institute for Pharmacological Research, Via Eritrea 62, I-20157 Milan, Italy. 4. Institute of Medical Statistics and Biometry, University of Milan-I, Via Venezian 1, I-20133 Milan, Italy.
References 1. Chishti P, Stone DH, Corcoran P, Williamson E, Petridou E on behalf of the Eurosave Working Group. Suicide mortality in the European Union. Eur J Public Health 2003; 13: 108-14. 2. Levi F, La Vecchia C, Lucchini F, Negri E, Saxena S, Maulik PK, et al. Trends in mortality from suicide, 1965-99. Acta Psychiatr Scand 2003; 108: 341-9. 3. Levi F, La Vecchia C, Saraceno B. Global suicide rates. Eur J Public Health 2003; 13: 97-8. 4. La Vecchia C, Bollini P, Imazio C, Decarli A. Age, period of death and birth cohort effects on mortality from suicide in Italy. 19551979. Acta Psychiatr Scand 1986; 74: 137-43. 5. Granizo JJ, Guallar E, Rodriguez-Artalejo F. Age-period cohort analysis of suicide mortality rates in Spain, 1959-1991. Int J Epidemiol 1996; 25: 814-20. 6. Foster T. Dying for a drink. Global suicide prevention should focus more on alcohol use disorders. Br Med J 2001; 323: 817-8. 7. Morrell S, Page A, Taylor R. Birth cohort effects in New South Wales suicide, 1865-1998. Acta Psychiatr Scand 2002; 106: 365-72 (Erratum in: Acta Psychiatr Scand 2003; 107: 160).
8. World Health Organization. International Classification of Disease: 9th Revision. Geneva: World Health Organization, 1977. 9. World Health Organization. International Classification of Disease: 8th Revision. Geneva: World Health Organization, 1967. 10.World Health Organization. International Statistical Classification of Disease and related Health Problems. 10th Revision. Geneva: World Health Organization, 1992. 11.Jougla E, Pequignot F, Chappert JL, Rossollin CF, Le Toullec A, Pavillon G. La qualité des données de mortalité sur le suicide. Rev Épidemiol Sante Publique 2002; 50: 49-62. 12.Cantor CH, Leenaars AA, Lester D. Under-reporting of suicide in Ireland 1960-1989. Arch Suicide Res 1997; 3: 5-12. 13.Kelleher MJ, Corcoran P, Keekey HS. Suicide in Ireland: statistical, social and clinical considerations. Arch Suicide Res 1997; 3: 13-24. 14.Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press, 1996. 15.Eddleston M, Sheriff MH, Hawton K. Deliberate self harm in Sri Lanka: an overlooked tragedy in the developing world. BMJ 1998; 317: 133-5. 16.Phillips MR, Li X, Shang Y. Suicide rates in China, 1995-99. Lancet 2002; 359: 835-40. 17.Zatonski WA, Boyle P. Health transformations in Poland after 1988. J Epidemiol Biostat 1996; 1: 183-7. 18.Kalediene R. Time trends in suicide mortality in Lithuania. Acta Psychiatr Scand 1999; 99: 419-22. 19.Leon DA, Chenet L, Shkolnikov VM, et al. Huge variation in Russian mortality rates 1984-94: artefact, alcohol, or what? Lancet 1997; 350: 383-8. 20.Shkolnikov V, McKee M, Leon DA. Changes in life expectancy in Russia in the mid-1990s. Lancet 2001; 357: 917-21. 21.Andreev EM, Nolte E, Shkolnikov VM, Varavikova E, McKee M. The evolving pattern of avoidable mortality in Russia. Int J Epidemiol 2003; 32: 437-46. 22.MacMahon B, Johnson S, Pugh T. Relation of suicide rates to social conditions. Public Health Rep 1963; 78: 285-93. 23.Lewis G, Sloggett T. Suicide, deprivation, and unemployment: record linkage study. Br Med J 1998; 317: 133-5. 24.Maris RW. Suicide. Lancet 2002; 360: 319-26. 25.Hall WD, Mant A, Mitchell PB, Rendle VA, Hickie IB, McManus P. Association between antidepressant prescribing and suicide in Australia, 1991-2000: trend analysis. BMJ 2003; 326: 1-5. 26.Webster P. Suicide rates in Russia on the increase. Lancet 2003; 362: 220.
RESP Informations
ARTICLE ORIGINAL Suicide mortality in adolescents and young adults, 1980-1999 Over the last two decades, overall mortality from suicide in the European Union, as well as in several Central and Eastern European countries (with the major exception of Russia and other countries of the former Soviet Union) has fallen appreciably, particularly in women. Likewise, appreciable declines in certified mortality from suicide were observed for women in the USA and for both sexes in Japan [1-3]. Rates have however increased in other countries, such as Cuba, Australia, New Zealand and some European countries (Iceland, Ireland, Italy, Spain), but, in spite of mixed trends, the global picture of suicide mortality has been relatively favourable across countries providing data to the WHO database [2]. Overall age-standardized suicide rates, however, may conceal different trends at different ages. These are not easily detectable by cohort analysis, since age effects may have major relevance on suicide rates [4]. Over recent years, in particular, upward trends in mortality from suicide in the young have been reported from several countries, including the UK, Ireland, Spain and Australia [5-7]. We have therefore updated trends in death certification rates from suicide over the last two decades in adolescent and young adults in 47 countries worldwide providing data to the WHO database [2].
METHODS Official death certification data for suicide were abstracted from the WHO database (http://www3.who.int/whosis/menu.cfm) over the period 1965-99, whenever available. Estimates of the resident population, generally based on official censuses, were based on the same WHO database. Although this database contains some data on mortality or population for a large number of countries, it was possible to obtain a meaningful and structured format (i.e., age-specific data for each sex, and for subsequent calendar years up to the late 1990’s) only for 47 of them. These included a total of 32 countries in Europe, 2 in North America, 5 in Latin America and the Caribbean, 1 in Africa, 5 in Asia, and 2 in Oceania. Data were missing for one or more calendar years for a few countries (as indicated in tables I and II). All countries providing meaningful data to analyze trends in suicide mortality over the calendar period considered were included, in the absence of any a priori exclusion. The European Union (EU) was defined as including the 15 member countries in 1999. Countries of the former Soviet Union included all those providing data to the WHO database in 1999. Countries may differ in ascertainment and classification criteria. In the 1990s, in fact, most countries utilized the Ninth Revision [8] of the International Classification of Diseases (ICD), but some still used the Eighth Revision [9] and some adopted the Tenth Revision [10] from 1995 onwards. Since differences between various Revisions were minor, suicide deaths were re-coded for all countries according to the Ninth Revision of the ICD (E 950-9). To improve
comparability across countries, probable suicides (ICD-9 E 980-9) were not included in the present analysis. From the matrices of certified deaths and resident populations in five-year age groups, age-specific rates for each calendar period were computed. Age-standardized rates at 15 to 24 and at 25 to 34 years were subsequently derived, on the basis of the world standard population.
RESULTS Table I gives age-standardized death certification rates from suicide at age 15 to 24 in various countries providing data to the WHO database. Figure 1 gives the corresponding trends in five selected major geographic areas (the EU, selected Eastern European countries, Russia, the USA and Japan). In the EU as a whole, suicide mortality declined by 6.6% in men and 20.8% in women. Among major Western European countries, suicide rates decreased in France and Germany, but increased in Italy, Spain and the UK. Consequently, they tended to level between 7 and 14/ 100,000 males, and between 2 and 4/100,000 females. Rates for young men were over 20/100,000 in a few other Western European countries, including Belgium, Ireland, Norway, Switzerland and mostly Finland (with a rate of 34.6/100,000 men in 1995-99), and even higher in Central and Eastern Europe, with rates around 25-27/100,000 men (but declining) in Hungary and Poland, of 34 to 48/100,000 in Estonia, Latvia and Lithuania, up to 52.8/ 100,000 in the Russian Federation. Russian suicide rates at age 15 to 24 showed an over 100% rise over the last two decades. For adolescent and young women, rates were around or over 6/ 100,000 in Belgium, Finland or Norway, up to 9/100,000 in the Russian Federation, again with appreciable and systematic upward trends over the last two decades. For adolescent and young men, suicide rates were around 10/100,000 in most South American countries providing data, but trends were upwards over the last two decades. Suicide rates were higher (around 20/ 100,000) in the USA and Canada, in the absence however of major trends over time. In 1995-99, Cuba had the highest suicide rates in women aged 15 to 24 worldwide (15.3/100.000 as compared to 13.3 in men). While rates in Israel, Hong Kong and Japan were similar to those in Western Europe, extremely high rates were observed in Australia (24.7/100,000 men aged 15 to 24, 5.7/100,000 women) and New Zealand (38.8 and 12.8 respectively), with substantial upward trends over time, i.e. over 100% during the last two decades in New Zealand. Table I and figure 2 give corresponding values at age 25 to 34 years. In the EU as a whole, the fall was 10.9% in men and 31.6% in women. For men, the range of variation was greater across major Western European countries, i.e. between 10.9/100,000 in Italy and 28.0 in France in the late 1990’s. Also trends over time were heterogeneous, with declines in France and Germany, but upward trends in Italy, the UK and, mostly, Spain, which however started from extremely low rates in the 1980’s. Among men, the lowest rates were in Portugal (7.4/100,000), Greece and Italy, and the highest ones in Latvia (62.7/100,000), Lithuania (74.5) and the Russian Federation (82.5), with appreciable upward trends in all these countries. Across Europe in women aged 25 to 34, only Russia (10.6) and Finland (12.9) had rates over 10/100,000, and most rates were downwards. Suicide rates at age 25 to 34 were around
591
Table I. — Trends in 15-24 year age-standardized (world population) death certification rates for suicide in Europe and other selected areas of the world, 1980-1999*. MALES COUNTRY
1980-84*
1990-94
FEMALES
1995-99*
1980-84*
1990-94
1995-99*
% CHANGE 95-99 vs 80-84
% CHANGE 95-99 vs 80-84
EUROPE AUSTRIA BELARUS (85-89) BELGIUM (95-96) BULGARIA CROATIA (85) CZECH REPUBLIC (86-89) DENMARK (95-98) ESTONIA (85-89) FINLAND FRANCE GERMANY** GREECE HUNGARY ICELAND (95-97) IRELAND ITALY LATVIA (85-89) LITHUANIA (85-89) LUXEMBOURG THE NETHERLANDS NORWAY POLAND (95-96,99) PORTUGAL ROMANIA (85-89) RUSSIAN FED. (85-89) SLOVAKIA (92-94) SLOVENIA (85-89) SPAIN SWEDEN SWITZERLAND UKRAINE (85-89) UNITED KINGDOM EUROPEAN UNION (95-98) AMERICAS ARGENTINA (95-96) CHILE (90-94) COSTA RICA (95) CUBA (75-79/94/95-96) MEXICO (95) CANADA (95-98) UNITED STATES
29.9 16.6 15.5 10.7 17.0 14.4 17.0 26.9 33.6 15.3 19.8 3.7 27.6 23.0 9.7 5.0 21.6 23.8 17.7 6.8 21.1 17.7 8.0 10.2 25.2
22.0 33.1 20.8 13.8 21.4 15.7 12.2 34.5 34.6 13.1 12.6 3.8 17.4 17.2 28.2 7.2 34.0 48.1 18.0 9.0 22.3 18.4 4.0 10.5 52.8 12.3 28.4 7.8 12.0 22.1 26.7 10.2 10.8
–26.5 99.9 34.1 28.9 25.5 8.6 –28.2 28.1 3.2 –14.5 –36.6 2.4 –37.0 –25.5 191.9 44.2 57.9 102.5 1.6 31.5 5.7 4.3 –50.6 2.8 109.8
7.9 3.8 4.8 5.6 5.2 4.5 5.7 7.3 6.0 4.9 5.9 1.7 8.6 2.7 2.7 1.7 5.9 6.0 5.2 3.7 4.0 4.1 4.9 4.1 5.7
26.0 5.0 15.3 34.4 14.7 7.1 11.6
23.2 23.0 17.1 14.1 21.6 15.3 11.9 28.8 40.4 14.7 12.8 4.7 21.0 35.0 18.6 6.3 30.8 32.0 21.9 8.7 23.5 16.7 5.8 9.7 36.5 13.6 27.4 7.0 12.9 24.2 19.3 11.2 11.1
9.3 55.3 –21.6 –35.7 81.3 43.5 –6.6
6.1 11.0 8.8 8.3 4.0 26.2 19.3
7.2 9.5 8.7 13.0 5.8 24.7 21.9
8.9
46.0
11.9 13.3 7.5 22.9 19.3
35.6 59.6 89.4 –12.6 0.1
18.6 10.5 10.0 12.7 9.0
13.5 73.9 72.8 –15.9 26.0
24.7 38.8
38.0 113.0
AFRICA, ASIA, AUSTRALIA AND OCEANIA MAURITIUS (85-89) 16.4 HONG KONG (95-96) 6.0 ISRAËL (95-98) 5.8 JAPAN 15.1 SINGAPORE 7.1 THAILAND (85-87/94) 11.5 AUSTRALIA 17.9 NEW ZEALAND (95-98) 18.2
17.8 8.2 10.6 9.9 10.1 5.3 25.3 38.5
9.4 1.3 5.7 9.0 4.1 2.2 3.7
5.8 4.4 4.2 4.6 5.1 4.0 3.3 8.4 7.3 4.3 3.5 0.7 6.0 3.1 3.0 1.7 6.1 7.6 2.7 3.4 5.3 2.7 2.2 3.1 7.5 2.4 6.5 1.7 5.3 5.5 4.6 2.1 2.9
4.1 5.7 5.8 4.4 5.1 3.2 3.2 6.5 7.1 4.0 3.4 0.7 3.7 4.9 4.7 1.7 6.3 7.8 4.3 3.8 6.6 2.8 1.5 2.6 9.2 1.7 6.0 2.0 5.5 5.7 4.9 2.4 2.9
–35.9 47.0 –4.0 –36.5 17.6 11.5 –20.8
3.9 3.2 3.4 19.6 1.5 4.6 4.2
3.0 1.9 2.9 15.4 1.4 5.0 3.8
3.3
–14.2
4.0 15.3 2.0 4.8 3.4
17.5 –22.2 37.0 4.5 –18.7
16.3 5.0 2.4 6.8 8.7 9.5 3.9 4.9
16.2 6.3 2.2 4.6 6.6 4.3 4.8 6.7
11.5 6.3 2.5 5.9 5.8
–29.5 26.0 5.9 –14.0 -33.1
5.7 12.8
46.8 160.0
* First and most recent period available, 1980-84 and 1995-99 respectively, unless otherwise mentioned in parenthesis. ** Including Federal and Democratic Republic of Germany before 1990.
–48.0 50.8 21.8 –20.9 3.3 –29.6 –44.6 –11.0 17.7 –19.1 –42.8 –57.8 –56.5 86.0 72.8 0.6 7.2 29.5 –16.1 3.0 65.2 –32.1 –68.9 –38.3 62.0
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RESP Informations
Table II. — Trends in 25-34 year age-standardized (world population) death certification rates for suicide in Europe and other selected areas of the world, 1980-1999*. MALES COUNTRY
FEMALES
1980-84* 1990-94 1995-99*
1980-84* 1990-94 1995-99* % CHANGE 95-99 vs 80-84
% CHANGE 95-99 vs 80-84
EUROPE AUSTRIA BELARUS (85-89) BELGIUM (95-96) BULGARIA CROATIA (85) CZECH REPUBLIC (86-89) DENMARK (95-98) ESTONIA (85-89) FINLAND FRANCE GERMANY** GREECE HUNGARY ICELAND (95-97) IRELAND ITALY LATVIA (85-89) LITHUANIA (85-89) LUXEMBOURG THE NETHERLANDS NORWAY POLAND (95-96,99) PORTUGAL ROMANIA (85-89) RUSSIAN FED. (85-89) SLOVAKIA (92-94) SLOVENIA (85-89) SPAIN SWEDEN SWITZERLAND UKRAINE (85-89) UNITED KINGDOM EUROPEAN UNION (95-98) AMERICAS ARGENTINA (95-96) CHILE (90-94) COSTA RICA (95) CUBA (75-79/94/95-96) MEXICO (95) CANADA (95-98) UNITED STATES
38.6 39.4 32.3 14.4 25.4 27.9 38.4 47.2 53.7 30.7 29.0 5.9 57.5 22.8 15.0 8.7 43.7 55.4 33.9 15.9 22.0 34.0 11.1 19.6 51.0
27.2 70.0 30.3 16.2 23.0 22.9 21.1 53.9 49.5 28.0 18.8 7.7 38.0 33.0 32.6 10.9 62.7 74.5 21.4 15.7 22.4 25.2 7.4 19.7 82.5 20.3 40.7 12.4 19.2 26.3 52.4 18.3 18.2
–29.4 77.5 –6.0 12.2 –9.5 –17.9 –45.2 14.2 –7.9 –8.7 –35.0 30.2 –33.9 44.9 117.3 25.5 43.5 34.5 –36.9 –1.2 2.1 –25.9 –32.9 0.5 61.8
10.0 5.6 12.3 5.1 8.3 7.6 15.9 10.2 12.0 10.2 10.0 2.1 15.8 3.4 4.4 3.1 8.6 9.8 9.8 8.9 7.0 5.5 4.6 4.1 7.0
48.2 6.8 31.6 39.1 36.5 14.2 20.4
29.8 49.0 29.9 18.1 31.2 24.6 24.9 56.7 61.3 31.8 21.4 5.8 51.3 26.5 27.7 10.8 64.7 63.7 22.0 15.6 25.8 29.1 13.6 17.7 68.9 23.1 44.6 11.5 23.3 33.1 41.6 17.3 19.9
10.4 1.8 12.0 14.1 4.9 4.3 6.9
7.9 6.2 9.4 5.6 6.8 7.0 7.2 8.7 11.9 8.9 5.9 1.4 10.6 3.0 5.4 2.9 9.1 8.3 6.2 7.1 7.1 4.2 3.6 3.9 8.8 3.5 8.2 2.7 9.6 8.8 5.7 3.9 5.4
4.1 8.1 9.5 5.8 5.0 3.7 4.6 5.0 12.0 8.0 4.9 1.4 7.5 5.2 5.3 2.8 8.5 9.1 8.8 6.5 6.7 3.1 1.8 3.1 10.6 2.5 8.4 2.7 6.6 7.2 6.9 3.8 4.7
–15.6 83.3 –39.2 –32.8 43.6 28.9 –10.9
8.9 13.0 15.4 11.9 4.6 29.5 25.3
9.0 13.8 11.8 23.2 7.0 28.2 24.9
9.2
3.6
14.9 23.3 9.2 25.0 23.8
–3.4 96.5 101.1 –15.4 –6.1
–19.0 47.0 –45.5 –48.8 40.2 –13.2 –31.6
3.5 2.2 2.6 11.0 1.1 7.8 6.8
3.2 2.2 1.9 14.7 1.0 6.1 5.2
2.4
–31.6
2.3 12.9 1.2 5.7 4.9
–9.7 17.4 3.5 –26.8 –27.7
13.1 9.9 3.8 8.3 9.1 2.9 6.5
11.3 7.9 2.1 9.8 7.9
188.5 –9.0 –51.9 –12.3 –16.4
7.3
9.8
7.5
8.0
13.7
AFRICA, ASIA, AUSTRALIA AND OCEANIA MAURITIUS (85-89) 9.6 HONG KONG (95-96) 13.5 ISRAËL (95-98) 10.2 JAPAN 25.4 SINGAPORE 13.8 THAILAND (85-87/94) 10.9 AUSTRALIA 23.7
31.0 14.2 12.6 18.6 14.3 8.4 29.5
33.9 16.3 10.6 23.1 13.6
254.8 20.8 3.2 –9.0 –1.3
35.4
49.5
3.9 8.6 4.4 11.2 9.4 5.9 6.6
NEW ZEALAND (95-98)
32.7
41.0
97.4
7.0
20.8
* First and most recent period available, 1980-84 and 1995-99 respectively, unless otherwise mentioned in parenthesis. ** Including Federal and Democratic Republic of Germany before 1990.
–29.1 42.9 –23.2 13.7 –40.0 –51.8 –70.9 –50.8 –0.2 –21.4 –50.5 –32.5 –52.8 –52.8 21.4 –9.6 –1.3 –7.3 –10.4 –27.1 –4.3 –43.2 –60.5 –24.3 51.4
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FIG. 1. — Trends in age-adjusted (world standard) death certification rates per 100,000 males (a) and females (b) aged 15-24 from suicide in European Union, six Eastern European countries (Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovakia), Russian Federation (period 1985-99), United States, and Japan, 1965-99.
20/100,000 men and 5/100,000 women in the USA, with a slight downward trend over time. As for the youngest age group, the highest rate registered worldwide at age 25 to 34 for women was in Cuba (12.9/100,000), as compared to 23.3 in men. Over recent calendar years, suicide rates at age 25 to 34 were 23.1/100,000 men and 9.8/100,000 women in Japan, with appreciable downward trends over time. In contrast, these were 35.4/100,000 men in Australia and 41.0 in New Zealand, with rises by about 50 and 100%, respectively, over the last two decades for males, but in the absence of clear trends in women over the same calendar period.
DISCUSSION The main observation from the present, systematic re-analysis of worldwide trends in suicide mortality in adolescent and young adults is the heterogeneous patterns of trends across various
countries and areas of the world over the last two decades. Thus, the overall favourable pattern of mortality from suicide at all ages registered over the last two decades in most Western countries (and Japan) [2, 3] was not reproduced in the young and even more in adolescents, mainly for men. For young women, suicide rates were favourable in the EU as a whole and Japan, but less consistent in other major areas of the world. Some of the apparent geographic variations, as well as some of the trends over time, may be due to changes in certification and coding of suicide deaths, since quality of mortality data on suicides worldwide is known to be variable [11]. These changes, partly related to modified socio-cultural attitudes towards suicide, may therefore explain some upward trends in selected countries, including Ireland [1, 12, 13]. In any case, the present analyses indicate that due caution is required for making general inference from trends observed in the young in any single country.
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RESP Informations
FIG. 2. — Trends in age-adjusted (world standard) death certification rates per 100,000 males (a) and females (b) aged 25-34 from suicide in European Union, six Eastern European countries (Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovakia), Russian Federation (period 1985-99), United States, and Japan, 1965-99..
On a cohort of death basis [4, 5, 7] some of the substantial rises in suicide rates in adolescent and the young observed in countries like Ireland, Russia, and other countries of the former Soviet Union, Cuba, Australia, or New Zealand could suggest that such massive upward trends can be maintained when the same cohorts will enter middle age. However, understanding age and cohort components in suicide rates is more complex than for chronic diseases [4], and consequently any long-term projection remains undefined. A limitation of the present study is its restriction to the WHO mortality database, including valid suicide mortality data over the last two decades only for 47 of the 191 member countries [2]. These do not include major countries like India, Sri Lanka or China, where suicide accounts for a substantial proportion of all deaths, particularly in the young [14-16]. Despite persisting high rates, suicide trends in the young over the last two decades have been favourable in Hungary, Poland
and other major former non-market economy Central European countries, reflecting underspread social improvements in these areas of the continent [17]. In contrast, on a public health level, the most worrisome aspect of the present analysis is given by extremely high rate of suicide among the young in Russia [18-21]. Russian suicide rate for males were over 50/100,000 at age 15 to 24, and over 80 and age 25 to 34, and similar values were observed in other countries of the former Soviet Union. This reflects social deprivation over the last two decades [22-24], as well as widespread alcohol abuse in these countries [21]. It is likely, on the other hand, that use of antidepressants [25] had a smaller favourable impact on suicide rates in the young, as compared to middle age and elderly populations. Whatever the underlying major reasons for the current suicide epidemic in Russia [26], this calls for urgent intervention to control an important and avoidable cause of death in the young.
595
ACKNOWLEDGEMENTS . — This study has been made possible by a core grant of the Swiss League against Cancer. Support was also received from the Italian Association for Cancer Research.
F. LEVI1, 2, F. LUCCHINI1, E. NEGRI3, C. LA VECCHIA1, 3, 4 1. Cancer Epidemiology Unit, University Institute of Social and Preventive Medicine, Bugnon 17, CH-1005 Lausanne, Switzerland. 2. Cancer Registry of Vaud, University Institute of Social and Preventive Medicine, CHUV Falaises 1, CH-1011 Lausanne, Switzerland. 3. Laboratory of Epidemiology, “Mario Negri” Institute for Pharmacological Research, Via Eritrea 62, I-20157 Milan, Italy. 4. Institute of Medical Statistics and Biometry, University of Milan-I, Via Venezian 1, I-20133 Milan, Italy.
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