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Trends of youth suicide in Europe during the 1980s and 1990s – gender differences and implications for prevention
Review
Trends of youth suicide in Europe during the 1980s and 1990s – gender differences and implications for prevention Ellenor Mittendorfer-Rutz
Keywords Gender
Abstract
Suicide
Youth suicide constitutes a considerable public health problem in many European countries. Suicide mortality in adolescents and young adults has increased during the 1980s and 1990s in several European countries and predominantly in young males. This paper summarises the international discussion on potential reasons for these trends, including changes in ascertainment practices, in the prevalence of psychopathology (mainly depression and substance abuse), in psychosocial and socio-economic conditions and in the methods chosen for suicidal behaviour. Potential reasons for the gender differences in trends are scrutinised. ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Youth Europe Prevention
Introduction
Ellenor Mittendorfer-Rutz, MSc, PhD National Institute of Psychosocial Medicine, Department of Public Health Sciences, Karolinska Institute, Box 230, SE-17177 Stockholm, Sweden E-mail: Ellenor.Mittendorfer-Rutz @ipm.ki.se
Online 7 September 2006
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Youth suicide rates vary greatly in Europe with a male:female ratio of about 2:1 and 8:1 (Fig. 1), with females being at least twice as likely to engage in suicide attempts than their male counterparts. Based on the latest available suicide mortality statistics from the WHO mortality database, suicide rates in male adolescents (15 to 19 years) ranged from less than 5 per 100,000 in some Southern European countries to rates of around 25 and even close to 40 per 100,000 in Northern and Eastern European countries (Fig. 1). Suicide often ranks among the three most common causes of death in youth. Suicide accounted for 4% and 21% of deaths in adolescents (15 to 19 years old) in Greece and Sweden, respectively (based on the mean proportion from 1999 to 2002 from the WHO mortality data base). Concerns about increasing youth suicide rates in the 1980s and 1990s in Western and Northern Europe have been raised repeatedly [1–4]. Several birth cohort analyses have repor-
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ted an increase in risk for later birth cohorts, particularly among young males [5,6], resulting in changes in rank order of suicide rates in adolescents, as witnessed by a relative stability in adults [7]. A comprehensive analysis of 30 European countries, including former Soviet Republics, revealed that from 1979 to 1996 male and female adolescent suicide rates have increased in 21 and 18 countries, respectively [8]. Increases in adolescent suicide rates were primarily accompanied by far fewer increases or decreases in suicide rates of individuals aged 20 years and over. With the exception of a few countries, male adolescent suicide rates rose faster than the female rate. The greatest increases in adolescent suicide rates (between a 4% and 8% statistically significant annual increase) were in the following countries: Lithuania, Spain, Kyrgyzstan, Latvia, Uzbekistan, Belarus, Ireland and Kazakhstan for males and Estonia, Lithuania, Kazakhstan, Belarus, Ukraine, Ireland and Norway for females [8]. The purpose of this review is a comprehensive scrutiny of the international discussion on:
ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Review
Figure 1
Suicide rates per 100,000, for male and female adolescents aged 15 to 19 years in the latest available year (listed in brackets) from 30 countries in the WHO European Region.
possible biological, behavioural and sociocultural explanations for these trends, gender aspects of (trends in) youth suicide rates and preventative measures to counteract the described trends.
Potential reasons for changes in youth suicide rates Classification practices Suicide in adolescence is estimated to be under-reported by around 30% or more [3,9]. A number of factors contribute to this under-
reporting: reluctance to classify deaths as suicides (mainly due to religious and social reasons), non-uniformity of ascertainment procedures, and variability in the training of those who certify the causes of death. Despite the consensus about the growth in incidence of youth suicide in the 1980s and 1990s, concerns have been raised, especially over whether some of the apparent growth is actually due to changes in reporting practices. Kelleher et al. observed that the proportion of deaths classified as ‘‘undetermined’’ was, in the mid 1990s, very much less in Ireland than in England and Wales and they estimated that around 40% of the rise in male suicides in
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Review Ireland since the late 1980s could be attributed to an improved gathering of statistical information [10]. The decrease in suicide rates in Portugal has been questioned, mainly due to the significant under-reporting of suicides with, since the beginning of the 1980s, many of which being registered instead as undetermined causes of death [8,11]. These changes in reporting practices might affect young males to a greater extent than young females [8,12]. A detailed analysis of trends in undetermined causes of death in male adolescents revealed that part of the observed increases in Sweden, Ireland and Greece could be attributed to improved suicide statistics, while increases in Finland, Belgium, Bulgaria and the United Kingdom could be even higher due to the rising classification of deaths as ‘‘undetermined’’ [8]. In Portugal, decreasing suicide trends seem to be misinterpreted by ignoring the vast increases in rates of undetermined deaths. Female adolescent suicide rates were only marginally affected by changes in classification practices.
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men more strongly than their female counterparts. This is even reflected in the perception of suicide in society. Suicide in response to problems with or at work is, in many countries, considered ‘‘masculine’’ [19].
Social and psycho-social factors
Family disruption An association between disrupted family background and the risk for suicide has been reported from psychological autopsy studies [20,21]. Results from aggregate-level studies suggest a positive association of divorce rate with suicide rates in youth [22,23]. Lone parenthood was found to be linked to an increase in suicide mortality and morbidity in offspring [24,25]. In several European countries, changes to the original family structure have been noted, including falling marriage rates and increasing numbers of legal separations [26]. Several authors have suggested that these changes contribute to the increase in suicide rates in the young [1,4,18]. This increase in family break-up, often with the loss of the father to the family, was proposed to have affected boys to a greater extent than girls due to the loss of their role model [27–29].
Socio-economic factors Socio-economic conditions such as unemployment and economic hardship have been associated with suicidal behaviour among adolescents and young adults [13–15]. A recent survey, in several European countries, found clear socio-economic inequalities in suicides, particularly in males [16]. Several authors have suggested that socio-economic changes could have contributed to the rising youth suicide rates, particularly in Eastern European countries in transition [1,4]. Severe recession and economic hardship characterised the structural crisis of the first phase of economic transition in most of these countries. The extremely rapid political and economic changes in the countries of the former USSR left young people with few options for employment. It has been suggested that adolescents, especially male adolescents, due to their as yet insecure position in life, are the ones most vulnerable to social changes [3,13,14,17,18]. Thus, the lack of a job could have had a different influence on the two sexes. Social position seems to be more strongly dependent on a particular working role for men compared to women. Losing a job appears to affect
Societal changes Societal changes, such as the decrease in church membership observed in several European countries, has been suggested to reflect not only a change in social integration but also a change in moral values and, therefore, in attitudes toward suicide and its occurrence [4,30]. In the Former Soviet Republics, for example, younger generations may have never had any education about religion or been involved in religious practices [31]. Other societal changes, like the increase in tertiary education in females, increased competition at school and changes in gender role models, were proposed to affect male adolescents more than females and put them at a greater risk for suicidal behaviour [4,18]. An increase in female tertiary education, which might indicate a change in the status of women and in family structures, has been related to changing suicide rates in European countries [32]. Furthermore, the transition from traditional rural, farming societies with a close social support system to more urban and industrialised societies might have increased the number of people living alone with lower social integration. This has been proposed to have contributed
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Review to the increase in suicide rates in Ireland, England, Wales and Belgium [2–4,33,34].
Methods used for suicidal behaviour In several studies the relationship between suicide attempt and suicide is decreasing and there seems to have been a shift to more lethal suicide methods in the last years in countries with increasing suicide rates [9,23,35,36]. A more frequent choice of suicide methods of higher lethality [37] in male adolescents has been stated to be contributive to the higher incidence of male suicide. It has been suggested that strong cultural beliefs of suicide being ‘‘masculine’’ and surviving a suicide as being culturally unacceptable, might influence young males in their decision to use more lethal means [19]. The great increase in female adolescent suicide rates in Norway during the 1980s and 1990s is also suggested to be due to an increase in the use of highly lethal, more masculine, suicide methods, mainly the use of hunting weapons which are easily available in Norway [8]. The preferred method of suicide attempt for young females is poisoning. The fact that most of the medication used for poisoning in Western countries is relatively low in lethality might also contribute to lower suicide rates in females. In Asia, females also often choose poisoning as the method for a suicide attempt, particularly pesticides with a high toxicity. The difference in the lethality of poisons in Europe compared to Asia has been suggested as an explanation for why Asian women die more often by suicide than Asian men [38].
Mental ill health Depression Depression is one of the major risk factors for suicide morbidity and mortality. Around 30% of suicide completers are reported to have suffered from a mood disorder when they committed suicide [39]. Various phenomena with regard to depressive disorders have been observed and discussed, for example, increases in the prevalence of depressive disorders in younger age groups [40–43] and increases in depressive disorders in young male suicides [1,44]. A number of authors have tried to attribute these changes in the prevalence of depression to the decrease in the average age of
menarche [41,45]. Diekstra & Garnefski have suggested that the lower age of puberty has caused a disjunction of biological development on the one hand and psychological and social development on the other [1]. Different correspondence rates in the prevalence of depressive disorders and the incidence of suicide in different European countries have been noted and proposed to reflect differences in the quality of, and access to, mental health care, in particular the recognition and treatment of depression. Rihmer et al. suggested that under-diagnosis of depression may have contributed to Hungary’s very high suicide rate as it showed a significant negative correlation with the rate of treated depression in the mid 1980s [46]. They further discussed the decrease in suicide rates in Hungary in the 1990s (even though unemployment, alcoholism and divorce rates increased and the average income decreased considerably after 1990), noting the possible effect of improvements in mental health care and crisis intervention [47]. Several explanations have been proposed for the reasons behind the phenomenon that depression is about twice as common in females as in males in epidemiological and psychological autopsy studies [48,49], while males commit suicide more than twice as often as females. Gender differences in the clinical manifestation of depression have been mentioned as underlying this paradox [50]. Rutz described a typical, atypical male depression which is characterised by a tendency to aggressive, externalising behaviour. Depression in males might, therefore, not have been detected by the general practitioners in his study, who were trained to improve their diagnosis and treatment of depression during an intervention programme. After the intervention suicide rates fell only in females and not in males. [50] As depression in females seems to be more easily detected, preventative efforts within psychiatric care are likely to reach a higher proportion of the young females than males at high risk for suicide. Furthermore, higher treatment rates due to better help-seeking behaviour and openness about mental problems or greater benefit from treatment for depression in females may, in part, explain the gender difference in depression and suicide rates [49,51]. Females may profit from better social networks and coping
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Review strategies. Females might even react to early signs of depression and their response to pressures or their endurance of episodes of depression before committing suicide may differ [49]. Recent evidence suggests that young females who commit suicide may have suffered from more severe psychopathology [49]. Females more often received a diagnosis of major depression and they had more often been in psychiatric care than their male counterparts. Alcohol and drug abuse Abuse of alcohol and other psychoactive substances, frequently co-morbid with depression, in adolescents is often associated with completed suicide [52,53]. Psychoactive substance use disorders have been reported in 26% to 62% of suicide victims under 20 years of age [53,54]. Several studies have reported a high and positive correlation between changes in national suicide rates among adolescents and young adults and changes in national alcohol consumption [17,55–57]. The age of onset of alcohol and illicit drug use seems to have dropped and the quantity and frequency of use in youth has increased in many European countries [17,26]. The increase in substance use among young people is suggested to be associated with greater availability and with an increased acceptability of their use by young people [17]. There are also tendencies towards an increase in problem drinking and the involvement of alcohol in suicide among adolescents and these are higher for boys than for girls in several countries [49,58,59]. Boys, in general, drink more frequently, are more often drunk and start earlier than their female counterparts [60]. The rising prevalence of substance abuse in male adolescents is also suggested as being involved in the observed increase in male suicide in some European countries [55]. Drinking patterns and the strength of their association with suicidal behaviour in adolescents appear to differ between European countries [26,58] and seem to be stronger in the northern, eastern and central European countries compared to southern Europe [4,57,61– 64]. Ramstedt proposed that the less intoxication-orientated drinking pattern of southern European countries appears to be more resistant to an elevated suicide-risk in younger age groups [61]. Particularly in the countries of the former Soviet Union, changes in alcohol consumption
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have been proposed as a major cause of the changes in suicide rates [62]. The sharp fall in suicide rates in the former USSR countries from 1984 to 1986–88 coincided with the restrictive alcohol policy of perestroika and the optimistic feeling for a better future that accompanied it [62,65]. The upward trend in male suicide rates that followed, which was particularly strong in the early 1990s, may likewise be related to the increased alcohol consumption linked to political changes, followed by economic hardship and the associated frustration. The relationship of socio-economic changes, alcohol consumption and trends in suicide mortality, however, is multi-faceted. Suicide mortality in Finland increased during an economic upswing from 1985 to 1990, and decreased during an economic recession from 1990 to 1995 [56]. The authors suggested that the high level of unemployment might have lowered alcohol consumption, and thereby suicide rates, through decreasing income in Finland. Externalising behaviour Males are reported to have higher rates of externalising behaviour, including antisocial, aggressive, impulsive and violent behaviour, often associated with substance abuse problems [66–70]. There is some evidence that this kind of behaviour has increased [69]. Males may be more prone to aggressive, antisocial and externalising behaviour and, therefore, they may make more impulsive, lethal, active and determined suicide attempts than their female counterparts [70].
Prevention Successful suicide prevention includes measures both within the health care services as well as within public health services. The majority of suicides occur in the presence of a mental disorder [39]. Improvements in both the diagnosis of depression and antidepression treatment, treatment with lithium and neuroleptics (particularly clozapine), as well as behavioural psychotherapies, have been evaluated and proven to be effective in suicide prevention [71]. Awareness of gender differences in the clinical manifestation of depression, however, seems to be important for
Review successful suicide prevention in depressed patients [50]. Several positive examples have also been published with regard to changing the environment. Toning down reports on suicidal acts in the media, influencing the availability of means for suicide as well as active follow-up of suicide attempters have all been shown to decrease suicide rates [71–75]. Positive examples for influencing the access to means of suicide include gun control and decreasing the package sizes of analgesics, a favoured drug for attempted suicide by poisoning. Suicide prevention may even start as early as during ante- and post-natal care, as suggested by recent evidence of long-term adverse consequences of early life experiences of parental psychosocial and psychiatric problems [76,77]. One ideal arena for effective suicide prevention in youth are schools. A comprehensive recent review of European national suicide prevention programmes revealed that all 13 European countries with national initiatives carry out educational programmes in schools [78]. Prevention programmes in schools may range from training of school personnel and psycho-educational programmes for students to screening of at-risk pupils. There also seems
to be a gender difference in the way these preventative programmes are perceived [79]. Young men seem not only to seek help less often than young women, but also seem to need different measures of psychosocial intervention and counselling.
Conclusion An increase in youth suicide rates was observed in several European countries during the 1980s and 1990s. This increase was more pronounced in young males. Possible explanations for gender differences in trends have been suggested on the basis of social, biological and behavioural changes. Further research disentangling the causes for these changes in youth suicide rates is warranted in order to develop and implement tailor-made suicide prevention programmes. Several suicide prevention strategies have proved effective for decreasing suicidal behaviour. These include improvement in the quality and access to mental health services and crisis centres, as well as public health interventions such as educational projects and programmes focussing on reduced access to the means for suicide and appropriate media reporting.
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Trends of youth suicide in Europe during the 1980s and 1990s – gender differences and implications for prevention Ellenor Mittendorfer-Rutz
Keywords Gender
Abstract
Suicide
Youth suicide constitutes a considerable public health problem in many European countries. Suicide mortality in adolescents and young adults has increased during the 1980s and 1990s in several European countries and predominantly in young males. This paper summarises the international discussion on potential reasons for these trends, including changes in ascertainment practices, in the prevalence of psychopathology (mainly depression and substance abuse), in psychosocial and socio-economic conditions and in the methods chosen for suicidal behaviour. Potential reasons for the gender differences in trends are scrutinised. ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Youth Europe Prevention
Introduction
Ellenor Mittendorfer-Rutz, MSc, PhD National Institute of Psychosocial Medicine, Department of Public Health Sciences, Karolinska Institute, Box 230, SE-17177 Stockholm, Sweden E-mail: Ellenor.Mittendorfer-Rutz @ipm.ki.se
Online 7 September 2006
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Youth suicide rates vary greatly in Europe with a male:female ratio of about 2:1 and 8:1 (Fig. 1), with females being at least twice as likely to engage in suicide attempts than their male counterparts. Based on the latest available suicide mortality statistics from the WHO mortality database, suicide rates in male adolescents (15 to 19 years) ranged from less than 5 per 100,000 in some Southern European countries to rates of around 25 and even close to 40 per 100,000 in Northern and Eastern European countries (Fig. 1). Suicide often ranks among the three most common causes of death in youth. Suicide accounted for 4% and 21% of deaths in adolescents (15 to 19 years old) in Greece and Sweden, respectively (based on the mean proportion from 1999 to 2002 from the WHO mortality data base). Concerns about increasing youth suicide rates in the 1980s and 1990s in Western and Northern Europe have been raised repeatedly [1–4]. Several birth cohort analyses have repor-
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ted an increase in risk for later birth cohorts, particularly among young males [5,6], resulting in changes in rank order of suicide rates in adolescents, as witnessed by a relative stability in adults [7]. A comprehensive analysis of 30 European countries, including former Soviet Republics, revealed that from 1979 to 1996 male and female adolescent suicide rates have increased in 21 and 18 countries, respectively [8]. Increases in adolescent suicide rates were primarily accompanied by far fewer increases or decreases in suicide rates of individuals aged 20 years and over. With the exception of a few countries, male adolescent suicide rates rose faster than the female rate. The greatest increases in adolescent suicide rates (between a 4% and 8% statistically significant annual increase) were in the following countries: Lithuania, Spain, Kyrgyzstan, Latvia, Uzbekistan, Belarus, Ireland and Kazakhstan for males and Estonia, Lithuania, Kazakhstan, Belarus, Ukraine, Ireland and Norway for females [8]. The purpose of this review is a comprehensive scrutiny of the international discussion on:
ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Review
Figure 1
Suicide rates per 100,000, for male and female adolescents aged 15 to 19 years in the latest available year (listed in brackets) from 30 countries in the WHO European Region.
possible biological, behavioural and sociocultural explanations for these trends, gender aspects of (trends in) youth suicide rates and preventative measures to counteract the described trends.
Potential reasons for changes in youth suicide rates Classification practices Suicide in adolescence is estimated to be under-reported by around 30% or more [3,9]. A number of factors contribute to this under-
reporting: reluctance to classify deaths as suicides (mainly due to religious and social reasons), non-uniformity of ascertainment procedures, and variability in the training of those who certify the causes of death. Despite the consensus about the growth in incidence of youth suicide in the 1980s and 1990s, concerns have been raised, especially over whether some of the apparent growth is actually due to changes in reporting practices. Kelleher et al. observed that the proportion of deaths classified as ‘‘undetermined’’ was, in the mid 1990s, very much less in Ireland than in England and Wales and they estimated that around 40% of the rise in male suicides in
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Review Ireland since the late 1980s could be attributed to an improved gathering of statistical information [10]. The decrease in suicide rates in Portugal has been questioned, mainly due to the significant under-reporting of suicides with, since the beginning of the 1980s, many of which being registered instead as undetermined causes of death [8,11]. These changes in reporting practices might affect young males to a greater extent than young females [8,12]. A detailed analysis of trends in undetermined causes of death in male adolescents revealed that part of the observed increases in Sweden, Ireland and Greece could be attributed to improved suicide statistics, while increases in Finland, Belgium, Bulgaria and the United Kingdom could be even higher due to the rising classification of deaths as ‘‘undetermined’’ [8]. In Portugal, decreasing suicide trends seem to be misinterpreted by ignoring the vast increases in rates of undetermined deaths. Female adolescent suicide rates were only marginally affected by changes in classification practices.
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men more strongly than their female counterparts. This is even reflected in the perception of suicide in society. Suicide in response to problems with or at work is, in many countries, considered ‘‘masculine’’ [19].
Social and psycho-social factors
Family disruption An association between disrupted family background and the risk for suicide has been reported from psychological autopsy studies [20,21]. Results from aggregate-level studies suggest a positive association of divorce rate with suicide rates in youth [22,23]. Lone parenthood was found to be linked to an increase in suicide mortality and morbidity in offspring [24,25]. In several European countries, changes to the original family structure have been noted, including falling marriage rates and increasing numbers of legal separations [26]. Several authors have suggested that these changes contribute to the increase in suicide rates in the young [1,4,18]. This increase in family break-up, often with the loss of the father to the family, was proposed to have affected boys to a greater extent than girls due to the loss of their role model [27–29].
Socio-economic factors Socio-economic conditions such as unemployment and economic hardship have been associated with suicidal behaviour among adolescents and young adults [13–15]. A recent survey, in several European countries, found clear socio-economic inequalities in suicides, particularly in males [16]. Several authors have suggested that socio-economic changes could have contributed to the rising youth suicide rates, particularly in Eastern European countries in transition [1,4]. Severe recession and economic hardship characterised the structural crisis of the first phase of economic transition in most of these countries. The extremely rapid political and economic changes in the countries of the former USSR left young people with few options for employment. It has been suggested that adolescents, especially male adolescents, due to their as yet insecure position in life, are the ones most vulnerable to social changes [3,13,14,17,18]. Thus, the lack of a job could have had a different influence on the two sexes. Social position seems to be more strongly dependent on a particular working role for men compared to women. Losing a job appears to affect
Societal changes Societal changes, such as the decrease in church membership observed in several European countries, has been suggested to reflect not only a change in social integration but also a change in moral values and, therefore, in attitudes toward suicide and its occurrence [4,30]. In the Former Soviet Republics, for example, younger generations may have never had any education about religion or been involved in religious practices [31]. Other societal changes, like the increase in tertiary education in females, increased competition at school and changes in gender role models, were proposed to affect male adolescents more than females and put them at a greater risk for suicidal behaviour [4,18]. An increase in female tertiary education, which might indicate a change in the status of women and in family structures, has been related to changing suicide rates in European countries [32]. Furthermore, the transition from traditional rural, farming societies with a close social support system to more urban and industrialised societies might have increased the number of people living alone with lower social integration. This has been proposed to have contributed
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Review to the increase in suicide rates in Ireland, England, Wales and Belgium [2–4,33,34].
Methods used for suicidal behaviour In several studies the relationship between suicide attempt and suicide is decreasing and there seems to have been a shift to more lethal suicide methods in the last years in countries with increasing suicide rates [9,23,35,36]. A more frequent choice of suicide methods of higher lethality [37] in male adolescents has been stated to be contributive to the higher incidence of male suicide. It has been suggested that strong cultural beliefs of suicide being ‘‘masculine’’ and surviving a suicide as being culturally unacceptable, might influence young males in their decision to use more lethal means [19]. The great increase in female adolescent suicide rates in Norway during the 1980s and 1990s is also suggested to be due to an increase in the use of highly lethal, more masculine, suicide methods, mainly the use of hunting weapons which are easily available in Norway [8]. The preferred method of suicide attempt for young females is poisoning. The fact that most of the medication used for poisoning in Western countries is relatively low in lethality might also contribute to lower suicide rates in females. In Asia, females also often choose poisoning as the method for a suicide attempt, particularly pesticides with a high toxicity. The difference in the lethality of poisons in Europe compared to Asia has been suggested as an explanation for why Asian women die more often by suicide than Asian men [38].
Mental ill health Depression Depression is one of the major risk factors for suicide morbidity and mortality. Around 30% of suicide completers are reported to have suffered from a mood disorder when they committed suicide [39]. Various phenomena with regard to depressive disorders have been observed and discussed, for example, increases in the prevalence of depressive disorders in younger age groups [40–43] and increases in depressive disorders in young male suicides [1,44]. A number of authors have tried to attribute these changes in the prevalence of depression to the decrease in the average age of
menarche [41,45]. Diekstra & Garnefski have suggested that the lower age of puberty has caused a disjunction of biological development on the one hand and psychological and social development on the other [1]. Different correspondence rates in the prevalence of depressive disorders and the incidence of suicide in different European countries have been noted and proposed to reflect differences in the quality of, and access to, mental health care, in particular the recognition and treatment of depression. Rihmer et al. suggested that under-diagnosis of depression may have contributed to Hungary’s very high suicide rate as it showed a significant negative correlation with the rate of treated depression in the mid 1980s [46]. They further discussed the decrease in suicide rates in Hungary in the 1990s (even though unemployment, alcoholism and divorce rates increased and the average income decreased considerably after 1990), noting the possible effect of improvements in mental health care and crisis intervention [47]. Several explanations have been proposed for the reasons behind the phenomenon that depression is about twice as common in females as in males in epidemiological and psychological autopsy studies [48,49], while males commit suicide more than twice as often as females. Gender differences in the clinical manifestation of depression have been mentioned as underlying this paradox [50]. Rutz described a typical, atypical male depression which is characterised by a tendency to aggressive, externalising behaviour. Depression in males might, therefore, not have been detected by the general practitioners in his study, who were trained to improve their diagnosis and treatment of depression during an intervention programme. After the intervention suicide rates fell only in females and not in males. [50] As depression in females seems to be more easily detected, preventative efforts within psychiatric care are likely to reach a higher proportion of the young females than males at high risk for suicide. Furthermore, higher treatment rates due to better help-seeking behaviour and openness about mental problems or greater benefit from treatment for depression in females may, in part, explain the gender difference in depression and suicide rates [49,51]. Females may profit from better social networks and coping
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Review strategies. Females might even react to early signs of depression and their response to pressures or their endurance of episodes of depression before committing suicide may differ [49]. Recent evidence suggests that young females who commit suicide may have suffered from more severe psychopathology [49]. Females more often received a diagnosis of major depression and they had more often been in psychiatric care than their male counterparts. Alcohol and drug abuse Abuse of alcohol and other psychoactive substances, frequently co-morbid with depression, in adolescents is often associated with completed suicide [52,53]. Psychoactive substance use disorders have been reported in 26% to 62% of suicide victims under 20 years of age [53,54]. Several studies have reported a high and positive correlation between changes in national suicide rates among adolescents and young adults and changes in national alcohol consumption [17,55–57]. The age of onset of alcohol and illicit drug use seems to have dropped and the quantity and frequency of use in youth has increased in many European countries [17,26]. The increase in substance use among young people is suggested to be associated with greater availability and with an increased acceptability of their use by young people [17]. There are also tendencies towards an increase in problem drinking and the involvement of alcohol in suicide among adolescents and these are higher for boys than for girls in several countries [49,58,59]. Boys, in general, drink more frequently, are more often drunk and start earlier than their female counterparts [60]. The rising prevalence of substance abuse in male adolescents is also suggested as being involved in the observed increase in male suicide in some European countries [55]. Drinking patterns and the strength of their association with suicidal behaviour in adolescents appear to differ between European countries [26,58] and seem to be stronger in the northern, eastern and central European countries compared to southern Europe [4,57,61– 64]. Ramstedt proposed that the less intoxication-orientated drinking pattern of southern European countries appears to be more resistant to an elevated suicide-risk in younger age groups [61]. Particularly in the countries of the former Soviet Union, changes in alcohol consumption
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have been proposed as a major cause of the changes in suicide rates [62]. The sharp fall in suicide rates in the former USSR countries from 1984 to 1986–88 coincided with the restrictive alcohol policy of perestroika and the optimistic feeling for a better future that accompanied it [62,65]. The upward trend in male suicide rates that followed, which was particularly strong in the early 1990s, may likewise be related to the increased alcohol consumption linked to political changes, followed by economic hardship and the associated frustration. The relationship of socio-economic changes, alcohol consumption and trends in suicide mortality, however, is multi-faceted. Suicide mortality in Finland increased during an economic upswing from 1985 to 1990, and decreased during an economic recession from 1990 to 1995 [56]. The authors suggested that the high level of unemployment might have lowered alcohol consumption, and thereby suicide rates, through decreasing income in Finland. Externalising behaviour Males are reported to have higher rates of externalising behaviour, including antisocial, aggressive, impulsive and violent behaviour, often associated with substance abuse problems [66–70]. There is some evidence that this kind of behaviour has increased [69]. Males may be more prone to aggressive, antisocial and externalising behaviour and, therefore, they may make more impulsive, lethal, active and determined suicide attempts than their female counterparts [70].
Prevention Successful suicide prevention includes measures both within the health care services as well as within public health services. The majority of suicides occur in the presence of a mental disorder [39]. Improvements in both the diagnosis of depression and antidepression treatment, treatment with lithium and neuroleptics (particularly clozapine), as well as behavioural psychotherapies, have been evaluated and proven to be effective in suicide prevention [71]. Awareness of gender differences in the clinical manifestation of depression, however, seems to be important for
Review successful suicide prevention in depressed patients [50]. Several positive examples have also been published with regard to changing the environment. Toning down reports on suicidal acts in the media, influencing the availability of means for suicide as well as active follow-up of suicide attempters have all been shown to decrease suicide rates [71–75]. Positive examples for influencing the access to means of suicide include gun control and decreasing the package sizes of analgesics, a favoured drug for attempted suicide by poisoning. Suicide prevention may even start as early as during ante- and post-natal care, as suggested by recent evidence of long-term adverse consequences of early life experiences of parental psychosocial and psychiatric problems [76,77]. One ideal arena for effective suicide prevention in youth are schools. A comprehensive recent review of European national suicide prevention programmes revealed that all 13 European countries with national initiatives carry out educational programmes in schools [78]. Prevention programmes in schools may range from training of school personnel and psycho-educational programmes for students to screening of at-risk pupils. There also seems
to be a gender difference in the way these preventative programmes are perceived [79]. Young men seem not only to seek help less often than young women, but also seem to need different measures of psychosocial intervention and counselling.
Conclusion An increase in youth suicide rates was observed in several European countries during the 1980s and 1990s. This increase was more pronounced in young males. Possible explanations for gender differences in trends have been suggested on the basis of social, biological and behavioural changes. Further research disentangling the causes for these changes in youth suicide rates is warranted in order to develop and implement tailor-made suicide prevention programmes. Several suicide prevention strategies have proved effective for decreasing suicidal behaviour. These include improvement in the quality and access to mental health services and crisis centres, as well as public health interventions such as educational projects and programmes focussing on reduced access to the means for suicide and appropriate media reporting.
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