Geographic variation in suicide rates: relationships to social factors, migration, and ethnic history

National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide

Background

Patient safety-based interventions aimed at lethal means restriction are effective at reducing death by suicide in inpatient mental health settings but are more challenging in the outpatient arena. As an alternative approach, we examined the association between quality of mental healthcare and suicide in a national healthcare system.

Methods

We calculated regional suicide rates for Department of Veterans Affairs (VA) Healthcare users from 2013 to 2017. To control for underlying variation in suicide risk in each of our 115 mental health referral regions (MHRRs), we calculated standardised rate ratios (SRRs) for VA users compared with the general population. We calculated quality metrics for outpatient mental healthcare in each MHRR using individual metrics as well as an Overall Quality Index. We assessed the correlation between quality metrics and suicide rates.

Results

Among the 115 VA MHRRs, the age-adjusted, sex-adjusted and race-adjusted annual suicide rates varied from 6.8 to 92.9 per 100 000 VA users, and the SRRs varied between 0.7 and 5.7. Mean regional-level adherence to each of our quality metrics ranged from a low of 7.7% for subspecialty care access to a high of 58.9% for care transitions. While there was substantial regional variation in quality, there was no correlation between an overall index of mental healthcare quality and SRR.

Conclusion

There was no correlation between overall quality of outpatient mental healthcare and rates of suicide in a national healthcare system. Although it is possible that quality was not high enough anywhere to prevent suicide at the population level or that we were unable to adequately measure quality, this examination of core mental health services in a well-resourced system raises doubts that a quality-based approach alone can lower population-level suicide rates.

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.

Ancestry and different rates of suicide and homicide in European countries: A study with population-level data

INTRODUCTION

There are large differences in suicide rates across Europe. The current study investigated the relationship of suicide and homicide rates in different countries of Europe with ancestry as it is defined with the haplotype frequencies of Y-DNA and mtDNA.

MATERIAL AND METHODS

The mortality data were retrieved from the WHO online database. The genetic data were retrieved from http://www.eupedia.com. The statistical analysis included Forward Stepwise Multiple Linear Regression analysis and Pearson Correlation Coefficient (R).

RESULTS

In males, N and R1a Y-DNA haplotypes were positively related to both homicidal and suicidal behaviors while I1 was negatively related. The Q was positively related to the homicidal rate. Overall, 60-75% of the observed variance was explained. L, J and X mtDNA haplogroups were negatively related with suicide in females alone, with 82-85% of the observed variance described.

DISCUSSION

The current study should not be considered as a study of genetic markers but rather a study of human ancestry. Its results could mean that research on suicidality has a strong biological but locally restricted component and could be limited by the study population; generalizability of the results at an international level might not be possible. Further research with patient-level data are needed to verify whether these haplotypes could serve as biological markers to identify persons at risk to commit suicide or homicide and whether biologically-determined ancestry could serve as an intermediate grouping method or even as an endophenotype in suicide research.

Differential correlation of suicide and homicide rates according to geographical areas: A study with population-level data

The current study investigated the relationship of suicide and homicide rates internationally. WHO database mortality data for 82 countries concerning suicide, homicides, and cancer and traffic accidents as controls were used. The analysis included Pearson correlation and multiple linear regression analysis. Worldwide homicidal rates explained 55.42%, 43.86% and 41.7% of male and 22.0%, 22.14% and 13.25% of female suicides for 2000, 2005 and 2010 respectively. In Europe there was a positive correlation between male suicide rates and all homicide rates including homicide rates in both genders, in male victims, and in female victims. In America there is no significant correlation. In Asia there is a significant correlation of male suicidal rates only with homicide rates of female victims. We observed marked and interesting differences in the pattern of association between Europe and the Americas. Overall the current paper suggests that at least in some human populations, suicidality and homicidality share common etiopathogenetic substrates and could be triggered by the same internal or external events or might develop based on common genetic background. Empirically it has been suggested that suicide is related to higher living standards while murder is related to poor quality of life and lower living standards.

A further test of the Finno-Ugrian Suicide Hypothesis: correspondence of county suicide rates in Romania and population proportion of ethnic Hungarians

Across the 42 counties of Romania, the total suicide rate and the population percentage of ethnic Hungarians were strongly positively interrelated (79% attributable variance). Counties with the strongest Hungarian minority had suicide rates converging to (or exceeding) the suicide rate for Hungary, which rate is high. Of a set of about 20 vital statistics and socioeconomic indicators, only life expectancy predicted a significant increment of further variance in the suicide rates. However, this effect was small, adding merely 3% further variance explained to 79% already accounted for. Overall, the findings are supportive of the Finno-Ugrian Suicide Hypothesis, i.e., the notion that geographic patterns of suicide prevalence may be partially due to genetic differences between populations. Supplemental analyses of a questionnaire item which specifically queried this study's main finding indicated widespread disbelief of this fact of suicide prevalence across a variety of samples, including two samples from Romania.

Testing the Finno-Ugrian Suicide Hypothesis: geographic variation of elderly suicide rates across Europe

The pattern of geographic variation in European suicide rates in the high-risk group of individuals aged 65 years and over was investigated, in order to provide a further test of the Finno-Ugrian Suicide Hypothesis, i.e. the assumption that genetic differences between populations may partially account for spatial differences seen in the suicide prevalence. National suicide rates (average of 1970-2002) of the elderly from 34 European countries were regressed on geographic position terms, i.e. capital cities' latitude and longitude, along with transformations (e.g. squared latitude) and interaction terms (e.g. latitude multiplied with longitude) of these, which statistically modeled various possible geographic gradients in the suicide rates. In these regression models, the strongest and statistically significant predictor of elderly suicide rates was an interaction term of squared latitude multiplied with longitude, indicating that suicide rates increased to the northeast. This accounted for 13.8% (total), 20.8% (males) and 11.6% (females) of the cross-national variance in elderly suicide rates. No further geographic position term accounted for a significant increment of further variance in suicide rates over and above this predictor. Controls for national quality of living conditions and alcohol consumption rates left these results essentially unchanged. Replicating previous evidence based on suicide rates of the general population, suicide rates of the elderly show a northeastern gradient across Europe. This J-shaped belt of high-suicide-rate countries spans from Central Europe (Austria, Hungary and Slovenia) to Northeastern Europe (Finland and the Baltic countries). There are early historical and genetic communalities among the populations inhabiting this area, but, in terms of culture, recent history, political systems and socioeconomic factors, there is great diversity between these countries. The current findings thus add to cumulated empirical evidence consistent with the Finno-Ugrian Suicide Hypothesis.

Testing the Finno-Ugrian suicide hypothesis: replication and refinement with regional suicide data from eastern Europe

Multiple lines of evidence indicate specific genetic contributions to suicidal behavior. In particular, geographic studies support the Finno-Ugrian Suicide Hypothesis, i.e., genetic differences between populations may partially account for geographic patterns of suicide prevalence. Specifically, within Europe the high suicide-rate nations constitute a contiguous J-shaped belt. The present research replicated and extended 2003 findings of Voracek, Fisher, and Marusic with new data. Across 37 European nations, an interaction term of squared latitude multiplied with longitude (quantifying the J-shaped belt) accounted for 32% of the cross-national variance in total suicide rates alone, while latitude accounted merely for 18% of variance over and above those. Refined analysis included regional data from countries critical for testing the hypothesis (89 regions of Belarus, western Russia, and the Ukraine) and yielded an even more clear-cut pattern (56% and 3.5%, respectively). These results are consistent with the Finno-Ugrian Suicide Hypothesis. Study limitations and directions for further research are discussed.

Ancestry, genes, and suicide: a test of the Finno-Ugrian Suicide Hypothesis in the United States

There is now convergent evidence from classic quantitative genetics (family, twin, and adoption studies) and molecular genetic studies for specific genetic risk factors for suicidal behavior. This emerging research field has recently been supplemented by geographical studies concerned with the Finno-Ugrian Suicide Hypothesis (FUSH), which states that population differences in genetic risk factors may partially account for conspicuous geographical patterns seen in suicide prevalence. In particular, the European high-suicide-rate nations constitute a contiguous, J-shaped belt, spanning from Finland to Austria. This area maps onto the second principal component identified for European gene distribution, most likely reflecting a major migration event of the past (i.e., the ancestral adaptation to cold climates and the Uralic language dispersion) still detectable in modern European populations. The present research tested the hypothesis in the United States. Consistent with the hypothesis, available historical (1913-1924 and 1928-1932) U.S. state suicide rates were uniformly positively associated with available state proportions of reported American ancestries from European high-suicide-rate countries (Hungary, Lithuania, Poland, Russia, Slovakia, and the Ukraine). However, contrary to the hypothesis, available contemporary (1990-1994) suicide rates were uniformly negatively associated with these ancestry proportions. The findings of this first test outside Europe are therefore conflicting. A proposal based on the geographical study approach is offered to further the progress of investigations into the genetics of suicide.