Divergent trends in suicide by socio-economic status in Australia

Suicide within five years of hospital-treated self-harm: A data linkage cohort study

BACKGROUND

Hospital-treated self-harm is a strong predictor of suicide and hospital contacts may include missed opportunities for suicide prevention. We conducted a data linkage study to identify factors associated with suicide in people treated in hospital for self-harm in Victoria, Australia.

METHOD

We undertook a cohort study following 14,307 people treated in hospital for an episode of self-harm (i.e., either admitted or non-admitted ED presentations) over the period 2011 and 2012 and used data from the Victorian Suicide Register to identify suicides within 5 years. We estimated unadjusted hazard ratios (HRs) for suicide using survival analysis for each exposure variable and then computed adjusted HRs using a multivariate model that included all exposure variables.

RESULTS

Among females, the risk of suicide was higher in those aged 50-74 years (HR 1.78; Cl: 1.02, 3.10), residing in areas of least disadvantage (HR 2.58; Cl: 1.21, 5.50), who used hanging as a method of self-harm (HR 5.17; Cl: 1.86, 14.35) and with organic disorders (HR 6.71; Cl: 2.61, 17.23) or disorders of adult personality and behaviour (HR 2.10; Cl: 1.03, 4.27). In males, the risk of suicide was higher in those who used motor vehicle exhaust gas (MVEG) as a method of self-harm (HR 3.48; Cl: 1.73, 7.01), and with disorders due to psychoactive substance abuse (HR 1.75; Cl: 1.14, 2.67).

CONCLUSION

Although all patients should be routinely assessed for risk and needs following hospital-treated self-harm including appropriate follow-up care, people who use MVEG or hanging as methods of self-harm are obvious candidates for close follow-up.

Socioeconomic disparities in suicide: Causation or confounding?

BACKGROUND

Despite an overall reduction in suicide, educational disparities in suicide have not decreased over the last decade. The mechanisms behind educational disparities in suicide, however, remain unclear: low educational status may increase the risk of suicide ("causation") or low educational status and suicide may share confounders. This paper assesses whether educational disparities in suicide (EDS) are more likely to be due to causation.

METHOD

The DEMETRIQ study collected and harmonized register-based data on mortality follow-up from forty population censuses from twelve European populations. More than 102,000 suicides were registered over 392 million person-years. Three analyses were carried out. First, we applied an instrumental variable approach that exploits changes in the legislation on compulsory educational age to instrument educational status. Second, we analyzed EDS by age under the hypothesis that increasing EDS over the life cycle supports causation. Finally, we compared EDS in men and women under the assumption that greater EDS in women would support causation.

FINDINGS

The instrumental variable analysis showed no evidence for causation between higher education and suicide, for men or women. The life-cycle analysis showed that the decrease of educational inequalities in suicide between the baseline 1991 period and the 2001 follow-up period was more pronounced and statistically significant in the first three younger age groups. The gender analysis indicated that EDS were systematic and greater in men than in women: the rate ratio of suicide for men with low level of education (RR = 2.51; 95%CI:2.44-2.58) was higher than the rate ratio in women (RR = 1.32; 95CI%:1.26-1.38).

INTERPRETATION

Overall, there was little support for the causation hypothesis, suggesting that the association between education and suicide is confounded. Educational inequalities in suicide should be addressed in early life by early targeting of groups who struggle to complete their education and display higher risk of mental disorder or of mental health vulnerabilities.

Rethinking Suicide in Rural Australia: A study Protocol for Examining and Applying Knowledge of the Social Determinants to Improve Prevention in Non-Indigenous Populations

Disproportionate rates of suicide in rural Australia in comparison to metropolitan areas pose a significant public health challenge. The dynamic interrelationship between mental and physical health, social determinants, and suicide in rural Australia is widely acknowledged. Advancement of this knowledge, however, remains hampered by a lack of adequate theory and methods to understand how these factors interact, and the translation of this knowledge into constructive strategies and solutions. This paper presents a protocol for generating a comprehensive dataset of suicide deaths and factors related to suicide in rural Australia, and for building a program of research to improve suicide prevention policy and practice to better address the social determinants of suicide in non-indigenous populations. The two-phased study will use a mixed-methods design informed by intersectionality theory. Phase One will extract, code, and analyse quantitative and qualitative data on suicide in regional and remote Australia from the National Coronial Information System (NCIS). Phase Two will analyse suicide prevention at three interrelated domains: policy, practice, and research, to examine alignment with evidence generated in Phase One. Findings from Phase One and Two will then be integrated to identify key points in suicide prevention policy and practice where action can be initiated.

The impact of strengthening mental health services to prevent suicidal behaviour

OBJECTIVE

Successive suicide prevention frameworks and action plans in Australia and internationally have called for improvements to mental health services and enhancement of workforce capacity. However, there is debate regarding the priorities for resource allocation and the optimal combination of mental health services to best prevent suicidal behaviour. This study investigates the potential impacts of service capacity improvements on the incidence of suicidal behaviour in the Australian context.

METHODS

A system dynamics model was developed to investigate the optimal combination of (1) secondary (acute) mental health service capacity, (2) non-secondary (non-acute) mental health service capacity and (3) resources to re-engage those lost to services on the incidence of suicidal behaviour over the period 2018-2028 for the Greater Western Sydney (Australia) population catchment. The model captured population and behavioural dynamics and mental health service referral pathways and was validated using population survey and administrative data, evidence syntheses and an expert stakeholder group.

RESULTS

Findings suggest that 28% of attempted suicide and 29% of suicides could be averted over the forecast period based on a combination of increases in (1) hospital staffing (with training in trauma-informed care), (2) non-secondary health service capacity, (3) expansion of mental health assessment capacity and (4) re-engagement of at least 45% of individuals lost to services. Reduction in the number of available psychiatric beds by 15% had no substantial impact on the incidence of attempted suicide and suicide over the forecast period.

CONCLUSION

This study suggests that more than one-quarter of suicides and attempted suicides in the Greater Western Sydney population catchment could potentially be averted with a combination of increases to hospital staffing and non-secondary (non-acute) mental health care. Reductions in tertiary care services (e.g. psychiatric hospital beds) in combination with these increases would not adversely affect subsequent incidence of suicidal behaviour.

Widening socioeconomic inequalities in Australian suicide, despite recent declines in suicide rates

PURPOSE

This study aims to investigate trends in socioeconomic inequalities of suicide from 1979 to 2013 for Australian males and females aged 15-34 years and 35-64 years.

METHODS

Data on suicides and population were obtained from national registries. An area-based measure of socioeconomic status (SES) was used, and categorized into low, middle, and high SES areas. Suicide rates for each SES groups were estimated using a negative binomial regression model, adjusted for confounders. Socioeconomic inequalities in suicide were assessed using absolute and relative risk of low-to-high SES areas. Secular changes in socioeconomic inequalities were assessed using trend tests for relative risk.

RESULTS

For young males, there was an increase in socioeconomic inequality driven by a significant decrease in suicide rates in high SES areas. For older males, inequality in suicide increased by 29%, which was related to a marked increase in suicide rates in low SES areas. Inequalities in both young and older female suicides also increased. These increases occurred when corresponding suicide rates in high SES areas decreased.

CONCLUSIONS

Recent widening socioeconomic inequalities in Australian suicide have been primarily associated with declines in suicide rates in high SES areas. However, an increasing inequality in older male suicide is linked with low SES. Efforts targeting people from poor areas, especially older males, should be considered when developing suicide prevention strategy.

Attention-deficit/hyperactivity disorder symptoms and suicidal behavior in adult psychiatric outpatients

AIM

We aimed to examine the association between attention-deficit/hyperactivity disorder (ADHD) symptoms and suicidal behavior in psychiatric outpatients and whether this association differs among patients with different psychiatric disorders.

METHODS

Cross-sectional data came from the Japan Prevalence Study of Adult ADHD at Psychiatric Outpatient Care, which included psychiatric outpatients aged 18-65 years recruited from one university hospital and three general psychiatric outpatient clinics in Kitakyushu City, Fukuoka, Japan from April 2014 to January 2015 (N = 864). The Adult ADHD Self-Report Scale (ASRS) Screener was used to collect information on ADHD symptoms. Reports of current and lifetime suicidal behavior were also obtained. A multivariable Poisson regression analysis was used to examine the association between ADHD symptoms and suicidal behavior.

RESULTS

After adjusting for covariates there was a strong association between possible ADHD (ASRS ≥14) and suicidal behavior with prevalence ratios ranging from 1.17 (lifetime suicidal ideation) to 1.59 (lifetime suicide attempt) and 2.36 (current suicidal ideation). When ASRS strata were used, there was a dose-response association between increasing ADHD symptoms and suicidal ideation and suicide attempts. Analyses of individual ICD-10 psychiatric disorders showed that associations varied across disorders and that for anxiety disorder, ADHD symptoms were significantly linked to all forms of suicidal behavior.

CONCLUSION

ADHD symptom severity is associated with an increased risk for suicidal behavior in general psychiatric outpatients. As ADHD symptoms are common among adult psychiatric outpatients, detecting and treating ADHD in this population may be important for preventing suicidal behavior.

Confluence of suicide and drug overdose epidemics in young Australian males: common causality?

BACKGROUND

Young adult (aged 20-34) males experience higher mortality than females, and in age groups immediately younger and older, and with considerable variation in death rates over time. Trends in mortality and the cause structure of deaths among young adult Australian males over 1979-2011 are investigated, with a focus on suicide and drug overdose.

METHODS

Mortality data by age for the period 1979 to 2011 and Australian population figures were obtained from the Australian Bureau of Statistics (ABS). Cause of death was investigated using relevant International Classification of Diseases (ICD) codes, and mortality by cause was examined graphically over time according to various ICD aggregations. Mortality trends were contextualised in relation to labour market changes occurring in Australia from the 1980s to early 2000s.

RESULTS

Although motor vehicle accident (MVA) mortality declined by half between 1980 and 1998 in males, this did not translate into a reduction in total young male mortality because of simultaneous increases in suicide, and drug-related deaths classified as either poisoning (external cause) or drug dependence (mental disorders). When both suicide and drug-related deaths declined concurrently after 1998, total 20-34 year male mortality declined by almost half (46%) over 1998-2011. Declines in external cause mortality accounted for 63% of the total mortality decline in 20-34 year males over 1998-2011. The close temporal coincidence (statistically significant) of increases and declines in suicide and drug-related deaths over a decade suggests related causality.

CONCLUSIONS

The coincidence of young male suicide and drug overdose mortality epidemics over the study period (excess deaths: 5000) suggest related causality such as exposure to common factors, including the labour market liberalisation and de-regulation of the 1990s, and deserves further investigation.

Suicide Risk among Immigrants and Ethnic Minorities: A Literature Overview

Recent studies have demonstrated that immigrants and ethnic minorities may be at higher risk of suicidal behaviour as compared to the general population. We conducted a literature search to identify studies in English from 1980 to 2017 related to suicide risk among immigrants and ethnic minorities. Six hundred and seventy-eight reports were screened, and 43 articles were included in the qualitative synthesis of the review. Some studies reported lower rates of suicide attempts, while other findings suggested higher rates of suicidal behaviour and deaths among immigrants as compared to the native population. Also, a positive correlation was found between suicidal behaviour and specific countries of origin. Non-European immigrant women were at the highest risk for suicide attempts, a group which included young women of South Asian and black African origin. Risk factors among migrants and ethnic minorities were found to be: language barriers, worrying about family back home, and separation from family. The lack of information on health care system, loss of status, loss of social network, and acculturation were identified as possible triggers for suicidal behaviour. Overall, results suggest that specific migrant populations and ethnic minorities present a higher risk of suicidal behaviour than native populations, as well as a higher risk of death by suicide.

Compositional, Contextual, and Collective Community Factors in Mental Health and Well-Being in Australian Rural Communities

There are disproportionately higher and inconsistently distributed rates of recorded suicides in rural areas. Patterns of rural suicide are well documented, but they remain poorly understood. Geographic variations in physical and mental health can be understood through the combination of compositional, contextual, and collective factors pertaining to particular places. The aim of this study was to explore the role of "place" contributing to suicide rates in rural communities. Seventeen mental health professionals participated in semi-structured in-depth interviews. Principles of grounded theory were used to guide the analysis. Compositional themes were demographics and perceived mental health issues; contextual themes were physical environment, employment, housing, and mental health services; and collective themes were town identity, community values, social cohesion, perceptions of safety, and attitudes to mental illness. It is proposed that connectedness may be the underlying mechanism by which compositional, contextual, and collective factors influence mental health and well-being in rural communities.

Does Gender Explain the Relationship Between Occupation and Suicide? Findings from a Meta-Analytic Study

This report investigated whether suicide risk by occupational groups differed for males and females. We examined this using a sub-set of articles examined in a recent meta-analysis and stratified by gender. For certain occupational groups, males and females had a similar risk of suicide (the military, community service occupations, managers, and clerical workers). There was some indication of gender differences for other occupations (technicians, plant and machine operators and ship's deck crew, craft and related trades workers, and professionals), although these did not reach statistical significance. These findings highlight the complexity of the relationship between occupation and suicide and suggest the possible role of a range of individual, work-related and social-environmental risk factors that may differ for males and females.

Who Leaves Suicide Notes? An Exploration of Victim Characteristics and Suicide Method of Completed Suicides in Queensland

The objective of this study is to address the question: are those who leave suicide notes representative of the larger population of those who commit suicide? The method involves an analysis of a full population of suicides by residents of Queensland, Australia for the full year of 2004, with the information drawn from Coronial files. Our overall results suggest that, and in support of previous research, the population who leaves suicide notes are remarkably similar to those who do not. Differences are identified in four areas: first, and in contrast to prior research, females are less likely to leave a suicide note; second, and in support of previous research, Aboriginal Australians are less likely to leave suicide notes; third, and in support of some previous research, those who use gas as a method of suicide are more likely to leave notes, while those who use a vehicle or a train are less likely to leave notes; finally, our findings lend support to research which finds that those with a diagnosed mental illness are less likely to leave notes. The discussion addresses some of the reasons these disparities may have occurred, and continues the debate over the degree to which suicide notes give insight into the larger suicide population.

The effects of involuntary job loss on suicide and suicide attempts among young adults: evidence from a matched case-control study

OBJECTIVE

To assess the influence of involuntary job loss on suicide and attempted suicide in young adults.

METHOD

A population-based case-control study of young adults (18-34 years) was conducted in New South Wales, Australia. Cases included both suicides (n=84) and attempts (n=101). A structured interview was conducted with next of kin (for suicide cases) and suicide attempters admitted to hospital. Controls selected from the general population were matched to cases by age and sex. Job dismissal or redundancy (involuntary job loss) in the 12 months before suicide or attempt was the main study variable of interest. Suicide and attempts were modelled separately and in combination as outcomes using conditional logistic regression modelling. The analysis was also adjusted for marital status, socio-economic status and diagnosis of an affective or anxiety disorder.

RESULTS

Following adjustment for other variables, involuntary job loss was associated with an odds ratio of 1.82 for suicide and attempted suicide (combined) (95% CI 0.98 to 3.37; p=0.058). Low socio-economic status was associated with an odds ratio of 3.80 for suicide and attempted suicide (95% CI 2.16 to 6.67; p<0.001) compared to high socio-economic status (after adjustment). Diagnosis of a mental disorder was associated with a 7.87 (95% CI 5.16 to 12.01; p<0.001) odds ratio of suicide and attempted suicide compared to no diagnosis (after adjustment). Involuntary job loss was associated with increased odds of suicide and attempts when these were modelled separately, but results did not reach statistical significance.

CONCLUSIONS

Involuntary job loss was associated with increased odds of suicide and attempted suicide. The strength of this relationship was attenuated after adjustment for socio-economic status and mental disorders, which indicates that these may have a stronger influence on suicide than job loss.

Emerging correlations between measures of population well-being, suicide and homicide: a look at global and Australian data

OBJECTIVE

Our aim was (1) to examine global and Australian data with a view to determining the presence of an inverse relationship between suicide and homicide rates, and (2) to examine global Human Development Index (HDI) values and suicide and homicide rates, with a view to determining any statistical relationship.

METHOD

Suicide and homicide rates and HDI values were available for 102 countries, and suicide and homicide rates were available for the states and territories of Australia. The three data sets had non-normal distributions, and the non-parametric Spearman's ρ was used for correlation statistics with α = 0.05.

RESULTS

We found a weak, statistically significant inverse relationship between the suicide and homicide rates of 102 countries (ρ = -0.244, p = 0.014). No relationship was established for the Australian values, however. As anticipated, we found a significant negative correlation between homicide and HDI values. We unexpectedly demonstrated a positive correlation between suicide rates and HDI values.

CONCLUSION

The notion that suicide and homicide have an inverse relationship now has some scientific support; but additional research is warranted to characterise and explain this relationship. The unexpected finding of a positive correlation between suicide rates and HDI values requires further examination.

Suicide rates and income in São Paulo and Brazil: a temporal and spatial epidemiologic analysis from 1996 to 2008

BACKGROUND

In a classical study, Durkheim noted a direct relation between suicide rates and wealth in the XIX century France. Since that time, several studies have verified this relationship. It is known that suicide rates are associated with income, although the direction of this association varies worldwide. Brazil presents a heterogeneous distribution of income and suicide across its territory; however, evaluation for an association between these variables has shown mixed results. We aimed to evaluate the relationship between suicide rates and income in Brazil, State of São Paulo (SP), and City of SP, considering geographical area and temporal trends.

METHODS

Data were extracted from the National and State official statistics departments. Three socioeconomic areas were considered according to income, from the wealthiest (area 1) to the poorest (area 3). We also considered three regions: country-wide (27 Brazilian States and 558 Brazilian micro-regions), state-wide (645 counties of SP State), and city-wide (96 districts of SP city). Relative risks (RR) were calculated among areas 1, 2, and 3 for all regions, in a cross-sectional approach. Then, we used Joinpoint analysis to explore the temporal trends of suicide rates and SaTScan to investigate geographical clusters of high/low suicide rates across the territory.

RESULTS

Suicide rates in Brazil, the State of SP, and the city of SP were 6.2, 6.6, and 5.4 per 100,000, respectively. Taking suicide rates of the poorest area (3) as reference, the RR for the wealthiest area was 1.64, 0.88, and 1.65 for Brazil, State of SP, and city of SP, respectively (p for trend <0.05 for all analyses). Spatial cluster of high suicide rates were identified at Brazilian southern (RR = 2.37), state of SP western (RR = 1.32), and city of SP central (RR = 1.65) regions. A direct association between income and suicide were found for Brazil (OR = 2.59) and the city of SP (OR = 1.07), and an inverse association for the state of SP (OR = 0.49).

CONCLUSIONS

Temporospatial analyses revealed higher suicide rates in wealthier areas in Brazil and the city of SP and in poorer areas in the State of SP. We further discuss the role of socioeconomic characteristics for explaining these discrepancies and the importance of our findings in public health policies. Similar studies in other Brazilian States and developing countries are warranted.

Suicide is preventable, sometimes

OBJECTIVE

The objective was to examine the assumption that suicide is inevitably preventable.

CONCLUSIONS

Suicide may not always be avoidable. This does not mean that every effort should not be made to prevent it or vigorously treat illnesses that are often contributory. The assumption, however, may give rise to undue optimism, and unjustified blame when suicides do occur.

Spatial clusters of suicide in Australia

BACKGROUND

Understanding the spatial distribution of suicide can inform the planning, implementation and evaluation of suicide prevention activity. This study explored spatial clusters of suicide in Australia, and investigated likely socio-demographic determinants of these clusters.

METHODS

National suicide and population data at a statistical local area (SLA) level were obtained from the Australian Bureau of Statistics for the period of 1999 to 2003. Standardised mortality ratios (SMR) were calculated at the SLA level, and Geographic Information System (GIS) techniques were applied to investigate the geographical distribution of suicides and detect clusters of high risk in Australia.

RESULTS

Male suicide incidence was relatively high in the northeast of Australia, and parts of the east coast, central and southeast inland, compared with the national average. Among the total male population and males aged 15 to 34, Mornington Shire had the whole or a part of primary high risk cluster for suicide, followed by the Bathurst-Melville area, one of the secondary clusters in the north coastal area of the Northern Territory. Other secondary clusters changed with the selection of cluster radius and age group. For males aged 35 to 54 years, only one cluster in the east of the country was identified. There was only one significant female suicide cluster near Melbourne while other SLAs had very few female suicide cases and were not identified as clusters. Male suicide clusters had a higher proportion of Indigenous population and lower median socio-economic index for area (SEIFA) than the national average, but their shapes changed with selection of maximum cluster radii setting.

CONCLUSION

This study found high suicide risk clusters at the SLA level in Australia, which appeared to be associated with lower median socio-economic status and higher proportion of Indigenous population. Future suicide prevention programs should focus on these high risk areas.

Suicide in young men

Suicide is second to only accidental death as the leading cause of mortality in young men across the world. Although suicide rates for young men have fallen in some high-income and middle-income countries since the 1990s, wider mortality measures indicate that rates remain high in specific regions, ethnic groups, and socioeconomic groups within those nations where rates have fallen, and that young men account for a substantial proportion of the economic cost of suicide. High-lethality methods of suicide are preferred by young men: hanging and firearms in high-income countries, pesticide poisoning in the Indian subcontinent, and charcoal-burning in east Asia. Risk factors for young men include psychiatric illness, substance misuse, lower socioeconomic status, rural residence, and single marital status. Population-level factors include unemployment, social deprivation, and media reporting of suicide. Few interventions to reduce suicides in young men have been assessed. Efforts to change help-seeking behaviour and to restrict access to frequently used methods hold the most promise.

Effectiveness of Australian youth suicide prevention initiatives

BACKGROUND

After an epidemic rise in Australian young male suicide rates over the 1970s to 1990s, the period following the implementation of the original National Youth Suicide Prevention Strategy (NYSPS) in 1995 saw substantial declines in suicide in young men.

AIMS

To investigate whether areas with locally targeted suicide prevention activity implemented after 1995 experienced lower rates of young adult suicide, compared with areas without such activity.

METHOD

Localities with or without identified suicide prevention activity were compared during the period of the NYSPS implementation (1995-1998) and a period subsequent to implementation (1999-2002) to establish whether annual average suicide rates were lower and declined more quickly in areas with suicide prevention activity over the period 1995-2002.

RESULTS

Male suicide rates were lower in areas with targeted suicide prevention activity (and higher levels of funding) compared with areas receiving no activity both during (RR = 0.89, 95% CI 0.80-0.99, P = 0.030) and after (RR = 0.86, 95% CI 0.77-0.96, P = 0.009) implementation, with rates declining faster in areas with targeted activity than in those without (13% v. 10% decline). However, these differences were reduced and were no longer statistically significant following adjustment for sociodemographic variables. There was no difference in female suicide rates between areas with or without targeted suicide prevention activity.

CONCLUSIONS

There was little discernible impact on suicide rates in areas receiving locally targeted suicide prevention activities in the period following the NYSPS.

Spatial distribution of suicide in Queensland, Australia

BACKGROUND

There has been a lack of investigation into the spatial distribution and clustering of suicide in Australia, where the population density is lower than many countries and varies dramatically among urban, rural and remote areas. This study aims to examine the spatial distribution of suicide at a Local Governmental Area (LGA) level and identify the LGAs with a high relative risk of suicide in Queensland, Australia, using geographical information system (GIS) techniques.

METHODS

Data on suicide and demographic variables in each LGA between 1999 and 2003 were acquired from the Australian Bureau of Statistics. An age standardised mortality (ASM) rate for suicide was calculated at the LGA level. GIS techniques were used to examine the geographical difference of suicide across different areas.

RESULTS

Far north and north-eastern Queensland (i.e., Cook and Mornington Shires) had the highest suicide incidence in both genders, while the south-western areas (i.e., Barcoo and Bauhinia Shires) had the lowest incidence in both genders. In different age groups (≤ 24 years, 25 to 44 years, 45 to 64 years, and ≥ 65 years), ASM rates of suicide varied with gender at the LGA level. Mornington and six other LGAs with low socioeconomic status in the upper Southeast had significant spatial clusters of high suicide risk.

CONCLUSIONS

There was a notable difference in ASM rates of suicide at the LGA level in Queensland. Some LGAs had significant spatial clusters of high suicide risk. The determinants of the geographical difference of suicide should be addressed in future research.

Trend of income-related inequality of child oral health in Australia

It is important that we monitor socio-economic inequality in health. Inequality in child oral health has been expected to widen because of widening socio-economic inequality. This study aimed to evaluate trends in income-related inequality in caries experience of Australian children. Cross-sectional studies in 1992/93 and 2002/03 collected data on deciduous caries experience of 5- to 10-year-olds and permanent caries experience of 6- to 12-year-olds. Household composition and income was used to calculate quartiles of equivalized income. Slope Index of Inequality (SII), Concentration Index (CI), and regression-based rate ratios were used to quantify income-related inequality and to evaluate trends. Income-related inequality in caries experience was evident regardless of time and dentition. The three indicators of inequality indicate a significant increase in income-related inequality in child deciduous caries experience during the decade. The income inequality in permanent caries experience did not change significantly. Income inequalities increased in deciduous teeth, but not in permanent teeth, among Australian children.

Recent declines in Australian male suicide are real, not artefactual

OBJECTIVES

The aim of the present study was to clarify the extent to which the recorded marked decline in young male suicide (20-34 years) in Australia since 1998 is attributable to misclassification of cause of death information.

METHODS

Secular trends in young male suicide rates were investigated for the period 1976-2005. Suicide rates in the period after the peak of the epidemic in this age group (1998) were re-calculated based on published estimates of under-enumeration of suicide data, and misclassification of likely suicide cases to other unintentional and undetermined external causes. Two misclassification scenarios were used to revise young male suicide rates from 1998: previously reported estimates of 9% under-enumeration due to misclassification of unintentional causes of death, and 17% under-enumeration due to misclassification of open cases in addition to unintentional causes of death. All-cause mortality was also examined.

RESULTS

Recorded male suicide in the 20-34 year age group increased over the study period, peaking in 1998 at 39 per 100,000, before declining sharply in the period 1999-2005 by 44% to 22 per 100,000 in 2005. Following adjustment for misallocation under the first scenario, suicide rates declined 38% to 24 per 100,000, and under the second scenario declined 33% to 26 per 100,000. Revised suicide rates were not materially different from recorded suicide rates based on 95% confidence intervals over this period. All-cause mortality declined from 1999 due to reductions in suicide and other causes.

CONCLUSION

The recent marked decline in young male suicide in Australia is real. The effects of misallocation of likely suicide cases to other causes did not substantially affect population trends in suicide rates in the period after 1998. There is still a need to account in detail for why young male suicide has declined so substantially during the period after 1998.

Socio-economic inequalities in suicide attempts and suicide mortality in Québec, Canada, 1990-2005

OBJECTIVES

Little research has evaluated changes in the association between area deprivation and suicidal behaviour over time. This study investigated patterns in suicide attempts and suicide mortality according to material deprivation in the province of Québec, Canada between 1990 and 2005.

STUDY DESIGN

Ecological analysis.

METHODS

Data on suicide attempts were extracted from the hospital discharge summary database (n=47,516) and data on suicides were extracted from the Québec death file (n=20,851). Gender- and age-specific (10-24, 25-44, 45-64 and > or = 65 years) suicide attempt and mortality rates were calculated for four time periods (1990-1993, 1994-1997, 1998-2001 and 2002-2005) for the entire Québec population aged 10 years and older residing in 162 communities ranked by decile of material deprivation. Absolute and relative measures of inequality were calculated to summarize differences between the most and least materially deprived areas. Commonly used methods of suicidal behaviour were examined.

RESULTS

Differentials in suicide attempt hospitalization between the most and least deprived areas were present for all age groups, and these decreased slightly among males and increased among females over time. Inequalities in suicide attempts were greatest among young adults (age 25-44 years) for both genders, and were smallest among the elderly (> or = 65 years). For suicide mortality, differentials increased among females but not males; these differentials were greatest among males and 25-44 year olds, and smallest among the elderly. Differentials in commonly used methods were evident for poisoning hospitalizations in both genders and for hanging deaths among males.

CONCLUSIONS

In Québec, differences in suicide attempts and mortality between the most and least materially deprived areas persisted or even increased over time. Inequalities were more pronounced for suicide attempts than for suicide mortality, and were greatest among adults of working age. Strategies to reduce socio-economic differences in suicidal behaviour may be important.

Suicide, big five personality factors, and depression at the American state level

The research determined the relation of the 2004-2005 American state suicide rates to state means on neuroticism, agreeableness, extraversion, openness, and conscientiousness as assessed by Rentfrow, Gosling, and Potter (2008). Multiple regression strategies were used to analyze relations between state suicide rates and state personality means with state socioeconomic status, White population percent, urban population percent, and depression rates controlled. Multiple regression analysis showed that neuroticism accounted for 32.0% and agreeableness another 16.3% of the variance in suicide rates when demographics and depression were controlled. Lower neuroticism and lower agreeableness were associated with higher suicide rates. Lower neuroticism and lower agreeableness may be important risk factors for completed suicide but not suicidal ideation or attempted suicide.

Two models of suicide

Objective: The aim of this paper is to present two models of separate but related aspects of suicide, developed with a view to improving understanding and management of this behaviour. Conclusions: First, the predicament model of suicide posits that all suicide represents an escape from a predicament and associated distress. Predicaments are composed of either external (environmental) or internal (mental disorders) factors, or both. Suicide occurs when a threshold is exceeded on a suicide risk ladder, and the degree of movement toward the threshold in response to a particular stressor depends on a range of factors. Second, the suicide pathways model integrates medical and sociological concepts, with distress as the central component, and three run-offs: mental disorder, medicalized and a non-mental disorder (egoistic/anomic; reaction) suicide.

Preliminary spatiotemporal analysis of the association between socio-environmental factors and suicide

BACKGROUND

The seasonality of suicide has long been recognised. However, little is known about the relative importance of socio-environmental factors in the occurrence of suicide in different geographical areas. This study examined the association of climate, socioeconomic and demographic factors with suicide in Queensland, Australia, using a spatiotemporal approach.

METHODS

Seasonal data on suicide, demographic variables and socioeconomic indexes for areas in each Local Government Area (LGA) between 1999 and 2003 were acquired from the Australian Bureau of Statistics. Climate data were supplied by the Australian Bureau of Meteorology. A multivariable generalized estimating equation model was used to examine the impact of socio-environmental factors on suicide.

RESULTS

The preliminary data analyses show that far north Queensland had the highest suicide incidence (e.g., Cook and Mornington Shires), while the south-western areas had the lowest incidence (e.g., Barcoo and Bauhinia Shires) in all the seasons. Maximum temperature, unemployment rate, the proportion of Indigenous population and the proportion of population with low individual income were statistically significantly and positively associated with suicide. There were weaker but not significant associations for other variables.

CONCLUSION

Maximum temperature, the proportion of Indigenous population and unemployment rate appeared to be major determinants of suicide at a LGA level in Queensland.

Suicide in paradise: aftermath of the Bali bombings

BACKGROUND

The relationship between the Bali (Indonesia) bombings of October 2002 and suicide has not previously been investigated, despite anecdotal evidence of the economic and psychological consequences of these attacks.

METHOD

Suicide rates were calculated over the period 1994-2006 in three Bali regencies to determine whether suicide increased in the period following the first Bali bombings. Poisson regression and time-series models were used to assess the change in suicide rates by sex, age and area in the periods before and after October 2002.

RESULTS

Suicide rates (age-adjusted) increased in males from an average of 2.84 (per 100 000) in the period pre-2002 to 8.10 in the period post-2002, and for females from 1.51 to 3.68. The greatest increases in suicide in the post-2002 period were in the age groups 20-29 and 60 years, for both males and females. Tourist arrivals fell significantly after the bombings, and addition of tourism to models reduced relative risk estimates of suicide, suggesting that some of the increase may be attributable to the socio-economic effects of declines in tourism.

CONCLUSIONS

There was an almost fourfold increase in male suicide risk and a threefold increase in female suicide risk in the period following the 2002 bombings in Bali. Trends in tourism did not account for most of the observed increases. Other factors such as indirect socio-economic effects and Balinese notions of collective guilt and anxieties relating to ritual neglect are important in understanding the rise in suicide in the post-2002 period.

Sociodemographic correlates of antidepressant utilisation in Australia

OBJECTIVE

To investigate sociodemographic variation in antidepressant utilisation.

DESIGN AND SETTING

Cross-sectional analysis of antidepressant prescription under the Pharmaceutical Benefits Scheme in Australia, 2003-2005.

MAIN OUTCOME MEASURES

Antidepressant utilisation (defined daily dose/1000/day) by sex, age, socioeconomic status (SES) and geographical area.

RESULTS

Total antidepressant utilisation increased with age. Among those aged > or = 15 years, female utilisation was about double that of males. About half of antidepressant utilisation was accounted for by sertraline, venlafaxine, citalopram, and paroxetine. SES differentials in antidepressant utilisation changed across age groups for males and females: among those aged < or = 19 years, total antidepressant utilisation was significantly less in lower SES groups (P < 0.001); there was no relationship to SES among 20-29-year-olds; and among those aged > or = 30 years, antidepressant utilisation was significantly higher in lower SES groups (P < 0.001). SES differences were attenuated after adjusting for urban or rural residence, but remained statistically significant. Antidepressant utilisation rates were highest in regional centres.

CONCLUSION

Antidepressant utilisation in Australia partially reflects sociodemographic differences in the prevalence of affective disorder. Discrepancies between treatment provision and treatment need suggest that not all social strata in Australia have equal access to these treatments.

Rural-urban differences in Austrian suicides

OBJECTIVES

The answer to the question whether suicide rates are higher in urban than in rural areas may have changed over the years. This study analyzes the longitudinal trends of rural and urban suicides in Austria from 1970 to 2005. The most recent decade, 1995-2005 was also investigated cross-sectionally in terms of age groups, gender, suicide methods and family status.

METHODS

Official suicide statistics were calculated in a Poisson regression model to determine trends in suicide rates according to gender in rural and urban regions as well as the ratios of rural- to urban-suicide rates. Population density levels were used as a measure of urbanization. Differences in suicide rates across the rural-urban categories were investigated in terms of genders, age groups, suicide methods and family status using Spearman correlations.

RESULTS

The ratio of rural to urban suicide rates has continuously increased in both genders over the past 35 years, indicating a growing risk in rural areas. Suicide methods used in rural and urban areas vary significantly and suicide rates among men, but not women, were found to decrease with increasing urbanicity.

CONCLUSION

In line with recent findings from other western countries, we showed a growing gap between rural and urban suicide rates. This suggests a need for rural-specific suicide prevention efforts, especially aimed at the male rural population.

Further increases in rural suicide in young Australian adults: Secular trends, 1979–2003

This study investigates changes in Australian urban-rural suicide differentials over time in the context of overall declines in (male) suicide in the late 1990s, and determines the extent to which differences in socio-economic status (SES) account for observed urban-rural trends. Suicide data were stratified for the period 1979-2003 by metropolitan, rural and remote areas and examined across five quinquennia, centred on each Australian census from 1981 to 2001. Suicide rates (per 100,000) were adjusted for confounding by sex, age, country-of-birth and the mediating effects of area SES, using Poisson regression models. Male suicide rates in metropolitan, rural and remote areas diverged significantly over time, especially in young males (15-24 years). Young male suicide rates increased significantly in metropolitan, rural and remote areas over 1979-1998, and in the most recent period (1999-2003) increased further in remote areas from 38.8 (per 100,000) to 47.9 (23% increase). In contrast suicide rates in rural areas decreased from a peak of 27.5 to 19.8 (28% decrease), and in metropolitan areas from a peak of 22.1 to 16.8 (24% decrease). Similar divergence in the 1999-2003 quinquennium, though of a lesser magnitude, was also evident for males aged 25-34 years. Female suicide rates in the earlier part of the period were significantly lower in rural and remote areas than in metropolitan areas, particularly for those aged 25-34 years, then increased in rural and remote areas to converge with female suicide rates in metropolitan areas. Adjusting for SES in addition to age and country-of-birth reduced urban-rural suicide differentials in both males and females, consistent with SES being an intermediary between rural residence and suicide. Nevertheless, urban-rural differences remained statistically significant. These results show that the largest urban-rural male suicide differentials for the 25-year study period occurred in the most recent period (1999-2003), in the context of decreasing male suicide rates overall.

Stigma towards people with mental illness in developing countries in Asia

BACKGROUND

There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996-2006.

METHOD

Medline search focusing on English-speaking literature.

RESULTS

Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing.

CONCLUSION

This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization-beliefs about causes of and attitudes towards mental illness, consequences for help-seeking-have more commonalities than differences to Western countries.