Socioeconomic differences in suicide mortality by sex in Finland in 1971—2000: A register-based study of trends, levels, and life expectancy differences

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.

Socio-demographic and economics factors associated with suicide mortality in Iran, 2001-2010: application of a decomposition model

BACKGROUND

Suicide is a major global health problem, especially among youth. Suicide is known to be associated with a variety of social, economic, political and religious factors, vary across geographical and cultural regions. The current study aimed to investigate the effects of socioeconomic factors on suicide mortality rate across different regions in Iran.

METHODS

The data on distribution of population and socio-economic factors (such as unemployment rate, divorce rate, urbanization rate, average household expenditure etc.) at province level were obtained from the Statistical Centre of Iran and the National Organization for Civil Registration. The data on the annual number of deaths caused by suicide in each province was extracted from the published reports of the Iranian Forensic Medicine Organization. We used a decomposition model to distinguish between spatial and temporal variation in suicide mortality.

RESULTS

The average rate of suicide mortality was 5.5 per 100,000 population over the study period. Across the provinces (spatial variation), suicide mortality rate was positively associated with household expenditure and the proportion of people aged 15-24 and older than 65 years and was negatively associated with the proportion of literate people. Within the provinces (temporal variation), higher divorce rate was associated with higher suicide mortality. By excluding the outlier provinces, the results showed that in addition to the proportion of people aged 15-24 and older than 65, divorce and unemployment rates were also significant predictors of spatial variation in suicide mortality while divorce rate was associated with higher suicide mortality within provinces.

CONCLUSION

The findings indicate that both spatial and temporal variations in suicide mortality rates across the provinces and over time are determined by a number of socio-economic factors. The study provides information that can be of importance in developing preventive strategies.

Socioeconomic inequalities in suicide in Europe: the widening gap

BACKGROUND

Suicide has been decreasing over the past decade. However, we do not know whether socioeconomic inequality in suicide has been decreasing as well.AimsWe assessed recent trends in socioeconomic inequalities in suicide in 15 European populations.

METHOD

The DEMETRIQ study collected and harmonised register-based data on suicide mortality follow-up of population censuses, from 1991 and 2001, in European populations aged 35-79. Absolute and relative inequalities of suicide according to education were computed on more than 300 million person-years.

RESULTS

In the 1990s, people in the lowest educational group had 1.82 times more suicides than those in the highest group. In the 2000s, this ratio increased to 2.12. Among men, absolute and relative inequalities were substantial in both periods and generally did not decrease over time, whereas among women inequalities were absent in the first period and emerged in the second.

CONCLUSIONS

The World Health Organization (WHO) plan for 'Fair opportunity of mental wellbeing' is not likely to be met.Declaration of interestNone.

Income-related inequality in completed suicide across the provinces of Iran

OBJECTIVES

The aim of this study was to measure income-related inequality in completed suicide across the provinces of Iran.

METHODS

This ecological study was performed using data from the Urban and Rural Household Income and Expenditure Survey-2010 conducted by the Iranian Center of Statistics, along with data on completed suicide from the Iranian Legal Medicine Organization in 2012. We calculated the Gini coefficient of per capita income and the completed suicide rate, as well as the concentration index for per capita income inequality in completed suicide, across the provinces of Iran.

RESULTS

The Gini coefficients of per capita income and the completed suicide rate in the provinces of Iran were 0.10 (95% confidence interval [CI], 0.06 to 0.13) and 0.34 (95% CI, 0.21 to 0.46), respectively. We found a trivial decreasing trend in the completed suicide incidence rate according to income quintile. The poorest-to-richest ratio in the completed suicide rate was 2.01 (95% CI, 1.26 to 3.22). The concentration index of completed suicide in the provinces of Iran was -0.12 (95% CI, -0.30 to 0.06).

CONCLUSIONS

This study found that lower income might be considered as a risk factor for completed suicide. Nonetheless, further individual studies incorporating multivariable analysis and repeated cross-sectional data would allow a more fine-grained analysis of this phenomenon.

Decomposing Socioeconomic Inequality Determinants in Suicide Deaths in Iran: A Concentration Index Approach

Background

It is recognized that socioeconomic status (SES) has a significant impact on health and wellbeing; however, the effect of SES on suicide is contested. This study explored the effect of SES in suicide deaths and decomposed inequality into its determinants to calculate relative contributions.

Methods

Through a cross-sectional study, 546 suicide deaths and 6,818 suicide attempts from January 1, 2010 to December 31, 2014 in Ilam Province, Western Iran were explored. Inequality was measured by the absolute concentration index (ACI) and decomposed contributions were identified. All analyses were performed using STATA ver. 11.2 (Stata Corp., College Station, TX, USA).

Results

The overall ACI for suicide deaths was -0.352 (95% confidence interval, -0.389 to -0.301). According to the results, 9.8% of socioeconomic inequality in suicide deaths was due to addiction in attempters. ACI ranged from -0.34 to -0.03 in 2010–2014, showing that inequality in suicide deaths declined over time.

Conclusion

Findings showed suicide deaths were distributed among the study population unequally, and our results confirmed a gap between advantaged and disadvantaged attempters in terms of death. Socioeconomic inequalities in suicide deaths tended to diminish over time, as suicide attempts progressed in Ilam Province.

Years of life lost due to external causes of death in the lodz province, poland

BACKGROUND

The aim of the study is the analysis of years of life lost due to external causes of death, particularly due to traffic accidents and suicides.

MATERIALS AND METHODS

The study material includes a database containing information gathered from 376,281 death certificates of inhabitants of the Lodz province who died between 1999 and 2010. The Lodz province is characterized by the highest mortality rates in Poland. The SEYLLp (Standard Expected Years of Life Lost per living person) and the SEYLLd (per death) indices were used to determine years of life lost. Joinpoint models were used to analyze time trends.

RESULTS

In 2010, deaths due to external causes constituted 6.0% of the total number of deaths. The standardized death rate (SDR) due to external causes was 110.0 per 100,000 males and was five times higher than for females (22.0 per 100,000 females). In 2010, the SEYLLp due to external causes was 3746 per 100,000 males and 721 per 100,000 females. Among males, suicides and traffic accidents were the most common causes of death (the values of the SEYLLp were: 1098 years and 887 years per 100,000 people, respectively). Among females, the SEYLLp values were 183 years due to traffic accidents and 143 years due to suicides (per 100,000 people).

CONCLUSIONS

A decrease in the number of years of life lost due to external causes is much higher among females. The authors observe that a growing number of suicides contribute to an increase in the value of the SEYLLp index. This directly contributes to over-mortality of males due to external causes. The analysis of the years of life lost focuses on the social and economic aspects of premature mortality due to external causes.

An ecological study on suicide and homicide in Brazil

The objective was to evaluate correlations between suicide, homicide and socio-demographic variables by an ecological study. Mortality and socio-demographic data were collected from official records of the Ministry of Health and IBGE (2010), aggregated by state (27). The data were analyzed using correlation techniques, factor analysis, principal component analysis with a varimax rotation and multiple linear regression. Suicide age-adjusted rates for the total population, men and women were 5.0, 8.0, and 2.2 per 100,000 inhabitants respectively. The suicide rates ranged from 2.7 in Pará to 9.1 in Rio Grande do Sul. Homicide for the total population, men and women were 27.2, 50.8, and 4.5 per 100,000, respectively. The homicide rates ranged from 13.0 in Santa Catarina to 68.9 in Alagoas. Suicide and homicide were negatively associated, the significance persisted among men. Unemployment was negatively correlated with suicide and positively with homicide. Different socio-demographic variables were found to correlate with suicide and homicide in the regressions. Suicide showed a pattern suggesting that, in Brazil, it is related to high socioeconomic status. Homicide seemed to follow the pattern found in other countries, associated with lower social and economic status.

Suicide mortality trends in the Nordic countries 1980-2009

BACKGROUND AND AIM

The Nordic countries provide a suitable setting for comparing trends in suicide mortality. The aim of this report is to compare suicide trends by age, gender, region and methods in Denmark, Finland, Iceland, Norway and Sweden 1980-2009.

METHODS

Suicide statistics 1980-2009 were analyzed for men and women aged 15 years and above and the age group 15-24 years. Regional suicide rates in 2009 were presented in maps.

RESULTS

The suicide rates across the Nordic countries declined from 25-50 per 100,000 in 1980 to 20-36 in 2009 for men and from 9-26 in 1980 to 8-11 in 2009 for women. The rates in Finland were consistently higher than those of the other countries. A significant increase of suicides in young women in Finland and Norway and a lack of a decline among young women in Sweden were noted. The male- female ratio of suicide converged to approximately 3:1 across the region during the study period. Rural areas in Finland, Norway and Sweden saw the highest suicide rates, whereas the rates in the capital regions of Denmark, Norway and Sweden were lower than the respective national rates.

CONCLUSIONS

We hold that the overall decline of suicide rates in the Nordic countries reflects the socio-economic development and stability of the region, including the well-functioning healthcare. The increasing rates in Finland and Norway and the unchanged rate in Sweden of suicide in young women are an alarming trend break that calls for continued monitoring.

Variation and seasonal patterns of suicide mortality in Finland and Sweden since the 1750s

OBJECTIVES

Suicide mortality varies in both the short and long term. Our study examines suicide mortality in Finland and Sweden from the 1750s until today. The aim of our study is to detect any seasonal peaks in suicide rates and examine their temporal evolution to suggest a mechanism that may explain such peaks.

METHOD

We acquired the study material from the Finnish and Swedish cause of death statistics (257,341 deaths by suicide) and the relevant population gender structure data. We then separately calculated the annual male and female suicide rates per 100,000 inhabitants. We analysed the suicide peaks, calculating factors of proportionality for the available data by dividing the suicide rates in the peak months (May and October) by the annual suicide rates.

RESULTS

Suicide rates in Finland and Sweden peak twice a year. Both men and women in both countries most often commit suicide in May. There is another peak in October, with the exception of Finnish men. These suicide peaks coincide with a temperature increase in May and the biggest annual drop in temperature in October. We also observed a monotonic long-term change in the Swedish statistics, but not in the Finnish data. Our hypothesis is that seasonal variation in suicide rates may be caused by abrupt temperature changes twice a year that trigger the activity in brown adipose tissue and deepen depression.

CONCLUSION

While the overall suicide mortality rates varied considerably, the monthly proportions in May did not. This finding suggests a routine factor underlying the spring peak in suicide mortality.

Experiences of health and well-being among Finnish low-income fathers

This article describes the everyday experiences of health and well-being among Finnish low-income fathers. The aim of study is to understand the health experiences of low-income fathers and the factors influencing the health experience and to develop nursing care in order to provide support for them. The approach is phenomenological and method is based on hermeneutical and descriptive phenomenology. The informants in this study were seven low-income Finnish fathers with children under 16 years old. Well-being of the fathers appeared as personal, realistic and bound to everyday life: income sufficient for meeting basic needs, everyday health, the pleasure and priviledge of life and the meaningfulness of the relationships in family and in community. Fathers used individual methods for maintaining the experience of well-being and they experienced the support from official sources as positive or negative. The findings of this study suggest that well-being of low-income fathers living under threat of marginalisation will be supported by care providers taking into account individual, social and economic factors, and that this support will have to be gender-sensitive, realistic and based on their everyday life.

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.

Spatial clusters of suicide in the municipality of São Paulo 1996-2005: an ecological study

BACKGROUND

In a classical study, Durkheim mapped suicide rates, wealth, and low family density and realized that they clustered in northern France. Assessing others variables, such as religious society, he constructed a framework for the analysis of the suicide, which still allows international comparisons using the same basic methodology. The present study aims to identify possible significantly clusters of suicide in the city of São Paulo, and then, verify their statistical associations with socio-economic and cultural characteristics.

METHODS

A spatial scan statistical test was performed to analyze the geographical pattern of suicide deaths of residents in the city of São Paulo by Administrative District, from 1996 to 2005. Relative risks and high and/or low clusters were calculated accounting for gender and age as co-variates, were analyzed using spatial scan statistics to identify geographical patterns. Logistic regression was used to estimate associations with socioeconomic variables, considering, the spatial cluster of high suicide rates as the response variable. Drawing from Durkheim's original work, current World Health Organization (WHO) reports and recent reviews, the following independent variables were considered: marital status, income, education, religion, and migration.

RESULTS

The mean suicide rate was 4.1/100,000 inhabitant-years. Against this baseline, two clusters were identified: the first, of increased risk (RR=1.66), comprising 18 districts in the central region; the second, of decreased risk (RR=0.78), including 14 districts in the southern region. The downtown area toward the southwestern region of the city displayed the highest risk for suicide, and though the overall risk may be considered low, the rate climbs up to an intermediate level in this region. One logistic regression analysis contrasted the risk cluster (18 districts) against the other remaining 78 districts, testing the effects of socioeconomic-cultural variables. The following categories of proportion of persons within the clusters were identified as risk factors: singles (OR=2.36), migrants (OR=1.50), Catholics (OR=1.37) and higher income (OR=1.06). In a second logistic model, likewise conceived, the following categories of proportion of persons were identified as protective factors: married (OR=0.49) and Evangelical (OR=0.60).

CONCLUSIONS

This risk/ protection profile is in accordance with the interpretation that, as a social phenomenon, suicide is related to social isolation. Thus, the classical framework put forward by Durkheim seems to still hold, even though its categorical expression requires re-interpretation.

Fetal growth, early life circumstances, and risk of suicide in late adulthood

Recent studies in Sweden and Scotland have found early life conditions to be associated with increased risk of attempted and completed suicide in adolescence and young adulthood. It is not known, however, whether early life conditions affect suicide risk throughout the life course, from adulthood into old age. We examined the effects of early life conditions, including markers of fetal growth, and social and economic characteristics in adulthood, on risk of suicide by violent and non-violent methods in women and men aged 31-87 years using Cox regression. 11,650 women and men born at the Uppsala University Hospital in Sweden between 1915 and 1929 were followed from 1960 until 2002 using linked records from obstetric archives, Census, population and mortality registries. During 435,039 person-years of follow-up 161 completed suicides (104 in males, 57 in females) were observed. An inverse association was found between lower birthweight-for-gestational age and risk of violent suicide in females, although the association did not reach the conventional level of statistical significance (minimally adjusted HR 2.02, 95% CI (0.88-4.63); Table 4). Being male, unmarried, and in the "other or unknown" social class category in adulthood were independently associated with increased rates of suicide. There was a weak association between higher maternal parity and suicide rates. Our findings suggest differences in effects of fetal growth patterns and perinatal circumstances on suicide risk later in life, and suggest that suicide in adults and in the elderly may be influenced by a different combination of factors than those that influence suicide in adolescence and young adulthood.

The contribution of psychological distress to socio-economic differences in cause-specific mortality: a population-based follow-up of 28 years

BACKGROUND

Psychological factors associated with low social status have been proposed as one possible explanation for the socio-economic gradient in health. The aim of this study is to explore whether different indicators of psychological distress contribute to socio-economic differences in cause-specific mortality.

METHODS

The data source is a nationally representative, repeated cross-sectional survey, "Health Behaviour and Health among the Finnish Adult Population" (AVTK). The survey results were linked with socio-economic register data from Statistics Finland (from the years 1979-2002) and mortality follow-up data up to 2006 from the Finnish National Cause of Death Register. The data included 32,451 men and 35,420 women (response rate 73.5%). Self-reported measures of depression, insomnia and stress were used as indicators of psychological distress. Socio-economic factors included education, employment status and household income. Mortality data consisted of unnatural causes of death (suicide, accidents and violence, and alcohol-related mortality) and coronary heart disease (CHD) mortality. Adjusted hazard ratios were calculated using the Cox regression model.

RESULTS

In unnatural mortality, psychological distress accounted for some of the employment status (11-31%) and income level (4-16%) differences among both men and women, and for the differences related to the educational level (5-12%) among men; the educational level was associated statistically significantly with unnatural mortality only among men. Psychological distress had minor or no contribution to socio-economic differences in CHD mortality.

CONCLUSIONS

Psychological distress partly accounted for socio-economic disparities in unnatural mortality. Further studies are needed to explore the role and mechanisms of psychological distress associated with socio-economic differences in cause-specific mortality.

Suicide mortality by occupation in Canada, 1991-2001

OBJECTIVE

To describe the association between occupation and risk of suicide among working-age men and women in Canada.

METHOD

This study of suicide mortality over an 11-year period is based on a broadly representative 15% sample of the noninstitutionalized population of Canada aged 30 to 69 years at cohort inception. Age-standardized mortality rates (ASMRs) and rate ratios were calculated for men and women in 5 categories of skill level and 80 specific occupational groups, as well as for people not occupationally active.

RESULTS

The suicide mortality rate was 20.1/100 000 person years for occupationally active men (during 9 600 000 person years of follow-up) and 5.3/100 000 person years for occupationally active women (during 8 100 000 person years of follow-up). Among occupationally active men, elevated rates of suicide mortality were observed for 9 occupational groups and protective effects were observed for 6 occupational groups. Among women, elevated rates of suicide were observed in 4 occupational groups and no protective effects were observed. For men and women, ASMRs for suicide were inversely related to skill level.

CONCLUSIONS

The limited number of associations between occupational groups and suicide risk observed in this study suggests that, with few exceptions, the characteristics of specific occupations do not substantially influence the risk for suicide. There was a moderate gradient in suicide mortality risk relative to occupational skill level. Suicide prevention strategies in occupational settings should continue to emphasize efforts to restrict and limit access to lethal means, one of the few suicide prevention policies with proven effectiveness.

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.

The role of socioeconomic indicators on non-alcohol and alcohol-associated suicide mortality among women in Finland. A register-based follow-up study of 12 million person-years

This study was to analyse the effects and interrelationships of three socioeconomic indicators--education, occupation-based social class and income--on non-alcohol and alcohol-associated suicide mortality among women in Finland. The register data used comprised the 1990 census records linked to the death register for the years 1991-2001 for women who were 25-64 years old in 1990. Adjusted relative mortality rates and the relative index of inequality (RII) were estimated using Poisson regression. The study population experienced 1926 suicides, of which 563 (29%) had alcohol intoxication as a contributory cause. The age-adjusted effects of education on non-alcohol associated suicide were modest, while social class and income related inversely and strongly. The effect of social class was partly mediated by income, and social class explained income differences to some extent. The associations between these socioeconomic indicators and alcohol-associated suicide were stronger, and following adjustment for each other large effects were left for education, social class and income. Further adjustment for living arrangements had little effect on socioeconomic differences in both types of suicide, but practically all of the effects of income and some of education and social class were mediated by employment status. In conclusion, current material factors are hardly the main underlying drivers of socioeconomic differences in suicide among Finnish women. Low social class proved to be an important determinant of suicide risk, but the strong independent effect of education on alcohol-associated suicide indicates that the roots of these differences are probably established in early adulthood when educational qualifications are obtained and health-behavioural patterns set.