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Mortality and Morbidity: Suicide
In recent years, suicide, especially among young people, has emerged as a major public health issue. Although death by suicide is a relatively uncommon event (in 1998, 2% of all deaths were attributed to suicide), the human and economic costs are significant. Apart from the loss of life, there are health care costs associated with attempted suicide, and it can be particularly difficult for friends and family to deal with the circumstances surrounding the death.
Recent government policy initiatives for suicide prevention began in 1992 when the National Health and Medical Working Group was set up to examine options for preventing suicide in Australia, and suicide prevention was identified as a target in 1994. The Commonwealth Government allocated $31m to the National Youth Suicide Prevention Strategy over four years from July 1995 to June 1999. From May 1999, it allocated a further $32m over four years to the Fighting Suicide initiative, including funds towards the implementation of the draft National Action Plan on Youth Suicide Prevention.1
TRENDS IN SUICIDE, 1921-1998(a)
Suicides since 1921
In 1921 there were 621 registered suicides, where many more men (510) took their lives than women (111). The age-standardised suicide rate was 14.0 deaths per 100,000 of the standard population. By 1998 the number of deaths from suicide had increased to 2,683 (2,150 males and 533 females) and the age standardised rate was 14.3 per 100,000.
Although the rates were similar in 1921 and 1998, there were a number of fluctuations during the intervening decades. The suicide rate rose during the depression years to peak at 16.8 per 100,000 in 1930. In this period, high suicide rates coincided with high levels of unemployment, particularly among males. In contrast, rates declined during World War II, falling below 8 per 100,000 people in both 1943 and 1944, the lowest recorded in Australia. The declining suicide rate during World War II was consistent with trends observed in many countries. However, rates for the war years may have been underestimated because suicides and any other deaths of troops overseas were not included in Australian death statistics.2
After the war, suicide rates began to rise gradually and again peaked in 1963 at 17.5 per 100,000. This rise and subsequent fall may be attributed in part to changes in the availability of hypnotic and sedative drugs, from unrestricted availability (following changes made to the National Health Act in 1960), to more restricted availability (following an amendment to the Act in 1967).3 After 1968, the standardised suicide rate remained fairly stable at approximately 13 per 100,000 until the mid 1990s. In 1997 it increased to 14.6, the highest recorded since 1971. The 1998 rate of 14.3 per 100,000 reflects a drop of 40 deaths from 1997.
Examination of data on deaths from suicide allows the identification of some of the main characteristics of those who commit suicide, such as age patterns, sex differentials, marital status and geographical location. This assists policy makers to better target their policies on suicide prevention to those most at risk.
Age and sex differentials
Since 1921 the male suicide rate has been consistently higher and more volatile than the female rate. Therefore, variations in the overall suicide rate were largely attributable to changes in the male rate.
The profile of age-specific death rates did not change substantially from the early 1920s to the late 1970s. After this period there were gradual but marked increases for men aged 25-44 and decreases for men aged 45 and over. The trends were similar for women, although the changes were smaller.
In 1921-25 suicides generally increased with age; by 1996-98 suicides were most common in the 25-44 year age groups and then generally declined slightly with age.
The biggest increase in deaths from suicide between 1921 and 1998 has been in the 15-24 years age group for men (rising from 8.6 deaths per 100,000 men in 1921-25 to 27.7 in 1996-98), and in the 75 and older age group for women (from 2.1 per 100,000 women in 1921-25 to 6.2 in 1996-98).
The ratio of men to women who commit suicide is not a reflection of the ratio of men to women who attempt suicide. According to results from the 1997 Survey of Mental Health and Wellbeing of Adults, women were about twice as likely as men to have attempted suicide in the 12 months prior to the interview. Reasons for the differences in attempts at suicide and completed suicides between men and women are not fully understood.
Married people are less likely to die from suicide than those who were never married, widowed or divorced. Over the most recent period for which suitable data is available (1995-97), people in registered marriages exhibited lower suicide rates than people who were not married (whether never married, divorced, or widowed).
Although the male rates of suicide for the years 1995 to 1997 were about four times as high as female rates, the relationship between marital status and standardised death rates from suicide was similar for men and women. The average suicide rates for males who had never married was more than twice as high as those for married males, and the rates for widowers and divorced men were about three times higher. Similar patterns were observed for women.
In 1998 there were 1,589 suicides in capital cities, 511 suicides in other urban areas and 557 suicides in rural areas. Despite year-to-year fluctuations, throughout the period from 1988 to 1998, persons living in capital cities had the lowest rates of suicide, (13 deaths per 100,000 persons in 1998); persons living in other urban areas had the next lowest (15 per 100,000 in 1998); and those in rural areas had the highest (17 per 100,000 in 1998). Possible explanations for high rural suicide rates for males include greater access to firearms, rapid technological changes and living in a climate of economic uncertainty.4
Associated causes of suicide
In 1997 the Australian Bureau of Statistics began tabulating all causes and conditions reported on death certificates. This process of recording multiple causes of death was introduced to give more detailed information about the underlying cause of death. It is now possible to identify not only the immediate cause of death but also other associated or contributory causes involved that may have indirectly influenced the death.
In 1998, 15% of men and 18% of women who committed suicide also had an associated or contributory diagnosis of a mental disorder, including 9% of men and 5% of women for whom substance use (usually abuse of alcohol or other drugs) was a factor. A further 4% of men and 9% of women who committed suicide were classified as having a depressive disorder.
In 1998, approximately 4% of males and 5% of females who committed suicide also had a disease of the circulatory system mentioned on their death certificate as an associated or contributory cause. No females, and less than 1% of males had the human immuno-deficiency virus (HIV) mentioned on their death certificate.
These results are supported by findings from the 1997 Survey of Mental Health and Wellbeing of Adults, which indicate that people with a mental disorder were nearly seven times more likely to have attempted suicide in the previous 12 months than people without a mental disorder (see Australian Social Trends 1999, Mental health).
Early death, regardless of the cause, is distressing, partly because the opportunity for a full range of life experiences has been curtailed. Premature mortality can be calculated in terms of the years of potential life lost if the individual survived a particular cause and were to die later of another cause. In this instance, premature mortality is assumed to be any death before the age of 75 years. By estimating potential years of life lost, it is possible to assess the significance of suicide as a cause of untimely death relative to other causes.
Between 1988 and 1998, the number of years of potential life lost from all causes of death decreased, while years of potential life lost due to suicide increased. This rise occurred because there has been an increase in both the overall number of suicide deaths (by nearly 500 deaths), and in the numbers of suicide deaths in the younger age groups. The years of potential life lost from suicide as a percentage of years lost from all causes of death increased from 7% to 11%.
Method of suicide
Most suicides (85%) reported in the period 1979-98 involved four methods: hanging and strangulation (25%), firearms and explosives (23%), carbon monoxide poisoning (19%), and poisoning by solid and liquid substances (18%). Other methods each contributed only a small proportion towards total suicide deaths during the period.
The methods of suicide chosen by men and women differed over the period 1979-98. Because male suicides account for the majority of all suicides, the methods chosen by men have a greater influence on the overall pattern than the methods chosen by females.
Over the period 1979-98, the most frequent method used by men was firearms (27%), followed by hanging (26%) carbon monoxide (20%), and poisoning (12%). Between 1979 and 1998 men’s use of firearms as a method of suicide declined from 7.0 to 2.4 per 100,000 persons. Firearms was the leading cause of suicide death among men until 1989, when hanging became the leading cause.
Male deaths from hanging increased from 2.6 in 1979 to 11.2 per 100,000 persons in 1998, and for deaths from carbon monoxide poisoning the rate increased from 2.2 to 5 per 100,000 persons.
Poisoning was the most common method of suicide for females until 1996. However, since 1997 hanging has become the most common method, accounting for 34% of suicide deaths in 1998, compared with 30% for poisoning.1
1 Australian Bureau of Statistics 2000, Suicides, Australia, 1921-1998, cat. no. 3309.0, ABS, Canberra.
2 Australian Bureau of Statistics 1997, Australian Demographic Trends, 1997, cat. no. 3102.0, ABS, Canberra.
3 Oliver, R.G. and Hetzel, B.S. 1972, 'Rise and fall of suicide rates in Australia: relation to sedative availability', Medical Journal of Australia, 2:919-923.
4 Ruzicka, L. and Choi, C.Y. 1999, 'Youth suicide in Australia', Journal of the Australian Population Association, 16: 1/2;29-46.