PERSPECTIVES of EPIDEMIOLOGY Silke Bachmann*, MD

In: Understanding Suicide ISBN: 978-1-53613-390-5 Editors: Patti Terry and Ron Price © 2018 Nova Science Publishers, Inc.

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Chapter 1

PERSPECTIVES OF EPIDEMIOLOGY

Silke Bachmann*, MD Department of Psychiatry, Psychotherapy, and Psychosomatics, University of Halle (Saale), Germany and Clienia Littenheid AG, Psychiatric Hospital, Littenheid, Switzerland

ABSTRACT

Suicides are a major problem as they account for 1.4% of premature deaths worldwide. The great majority of suicides and suicide attempts are related to mental illness. Special risk has been attributed to depression, psychosis, substance use, personality and trauma-related disorders. Most of these disorders begin in adolescence or young adulthood, which may be related to the fact that suicide is the second leading cause of death up to the age of 30 and the the third most common cause of death up to the age of 44. According to the WHO, globally, 78% of all completed suicides occur in low- and middle-income countries. In 2015, close to 800,000 suicides were documented worldwide, but under-reporting due to illegality and taboo is likely to form the basis of enormous bias. Most commonly, the following methods are used: hanging, self-poisoning with pesticides, and use of firearms. Suicide rates differ over a lifetime and among the sexes. Men take their lives three times as often as women, whereas suicide attempts are three times as common in women compared to men. Overall,

* Corresponding Author Email: [email protected]. 2 Silke Bachmann

attempts are 5-30 times as frequent as completed suicides and they are predictors of repeated attempts as well as of completed suicides. Although suicidality is a complex issue on several levels, suicides are partially preventable by addressing the way of reporting in the media, by restricting access to means of suicide, by training health workers and primary care physicians to identify people at risk as well as to assess and manage respective crises and provide adequate follow-up care. However, suicidality is not just a health care issue, and it should be given high priority in many political and social spheres as well.

Keywords: suicidality, suicide, worldwide, epidemiology, age, gender, mental disease

INTRODUCTION

Suicides are responsible for about 800,000 premature deaths every year, which translates to one suicide every 40 seconds. The World Health Organization (WHO) estimates the global annual mortality to be 10.7 per 100,000 individuals (see Figures 1 and 3). Suicide is a worldwide phenomenon. In 2015, 78% of suicides occurred in low- and middle-income countries (LMIC). The overall mortality rate of 1.4% ranged from 0.5% in the African region to 1.9% in the South-East Asian region (Värnik 2012). Although suicides occur at any age, it is the second leading cause of death among 15-29 year olds and the third leading cause among 15-44 year olds globally (Bertolote & Fleischmann 2002a). The great majority of suicides and suicide attempts are related to mental illness. Reported numbers concerning the percentage of completed suicides related to a mental illness amounts to 60%-98% (Bertolote & Fleischmann 2002a, Bertolote et al. 2004, Chang et al. 2011, Ferrari et al. 2014, Röcker & Bachmann 2015). Personal crises in the context of problems regarding relationships and finances account for many of the remaining cases. Other reasons also include victimization by, for example, discrimination (Virupaksha et al. 2016), violence (Van Dulmen et al. 2013, Kiss et al. 2015, Lacey et al. 2015), terror, and war (Grubisic-Ilic et al. 2002, Selakovic- Bursic et al. 2006, Oron Ostre 2012). Perspectives of Epidemiology 3

Although present, worldwide information about suicidality and suicides varies to a great extent between countries. For different reasons, hardly any numbers are available for some parts of the world and reliability of information has to be called into question for other parts. Thus, literature on suicidality mostly originates from Western civilization and is likely to ignore the living conditions and attitudes towards life of a larger number of human beings, as is the case in the presented chapter.

Reprint with permission of WHO (WHO 2017e).

Figure 1. Suicide: Facts and figures, WHO 2017. 4 Silke Bachmann

Therefore, the necessary definitions are followed by a discussion of the scope and the quality of data on which this chapter is based. The major part consists of the relevant epidemiological data on suicide and suicidality, occurrence in different countries, age and gender distribution, and the role of psychiatric illness. With respect to several of the aspects mentioned above, the World Health Organization (WHO) provides the best possible data sets from its 193 member states. The WHO was founded in 1948 and started suicide monitoring in 1950 (WHO 2014). From their vast and mostly unbiased information this chapter’s basis will be drawn. Very condensed information can be found in a poster released by the WHO (Figure 1). Due to its concentration on a few numbers and emblematic illustrations, it can be used in a variety of contexts.

Definitions

Nowadays, in suicidology the following expressions are in use and are considered as adequate: suicide, completed suicide, suicidality, and self- harm including suicide attempts. Suicide is the act of deliberately killing oneself. This seemingly clear cut definition does not withstand questions like: Can death from starvation in anorexia be called suicide in parallel to voluntary starvation and dehydration, known in palliative care? (Quill et al. 1997, Jacobs 2003). Self-harm is a broader term corresponding to self-inflicted physical harm with or without the intention to die. Even if not intended, a fatal outcome may be taken into account. Suicide attempts are included here. Many other terms have been used or are still in use, such as self-injury, self- harm, deliberate self-harm, self-directed violence, parasuicide, attempted suicide, suicidal spectrum, fatal and non-fatal suicidal behavior, and self- harm with/with uncertain/without suicidal intent, to commit suicide (Silverman 2006, Silverman et al. 2007). Some of these expressions focus on outcome, while others focus on intentions such as attention-seeking, relief from something unbearable, or self-punishment (Dammann & Gerisch Perspectives of Epidemiology 5

2005, Pfab et al. 2006, Yuodelis-Flores & Ries 2015). Differing terminologies and/or concepts, intents, and motivations seriously hamper research in the field of suicidology. Therefore, along the descriptive lines, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association 2013) instituted a new terminology: “nonsuicidal self-injury” (NSSI) in addition to “suicide behavior disorder” and suicide in the context of a specific disease. Here, the terms suicide, completed suicide, suicidality, and suicide attempt will be used. As other forms of self-harm are beyond the scope of this chapter, the term will be avoided whenever possible.

Quality of Data

“… stigmatized causes of death, such as suicide, are routinely miscoded; the miscoding rate varies by setting.” (WHO 2017) Research on suicide and suicide attempts faces certain caveats, some of which exist globally, while others pertain to certain countries or subgroups. Globally speaking, both suicides and suicide attempts may not be recognized as such (see Figure 2). Both may be misdiagnosed as either accidental or deliberate, which holds true for poisoning, car accidents, and another wide range of injuries. WHO researchers assume that underreporting of suicides ranges between 20% and 100% (Bertolote & Fleischmann 2002b). This partially goes back to beliefs, stigma, and taboo. The higher rate of under- reporting and misclassification – more than in other areas of medicine – may be related to the political and legal situation in a country (e.g., all suicidal acts are liable to prosecution in a number of countries) (Bertolote & Fleischmann 2002b). Also, a lack of knowledge and experience of the medical professionals may account for the most common misdiagnoses of death: fall; accidental drowning and submersion; exposure to smoke or fire; accidental poisoning by and exposures to noxious substances; and assault. These and all other external causes are listed in ICD-10 codes R, V-Y (WHO 2016). In some cases, the correct diagnosis simply cannot be made, e.g., if information is 6 Silke Bachmann missing. This is often the case in drug overdosing, which may well be classified as either an accident or a suicide depending on the situation. Understandably, unclear medical situations will rather not be labelled suicide. However, care should be taken not to follow a certain trend, for example, using injury codes for accidental poisoning instead of death due to acute alcohol-intoxication or acute opioid-overdose (even if of an unclear cause). Not surprisingly, a group who reviewed 114 studies came to the conclusion that higher quality studies report higher suicide rates (Jordans et al. 2014). In 2012, WHO comprised 172 member states. When suicide mortality data were assessed, registration, resp. the data basis for suicide estimations, was said to be of good quality (WHO) in only 60 states. It was assumed that 71% of global suicides had occurred in the other 112 states. As suspected, the quality of registers depends on financial resources: “39 high- income countries with good vital registration data account for 95% of all estimated suicides in high-income countries”, whereas good quality data were available only from 21 low- and middle income countries (LMIC), capturing 8% of the suspected suicides in these countries.

Reprint with permission of WHO (WHO 2012).

Figure 2. Quality of suicide mortality data, 2012. Perspectives of Epidemiology 7

Table 1. Countries for which suicide specifications dated back more than 5 years in 2015, drawn from WHO Mortality data base (WHO 2016a). Other countries did not report any data at all

Region Last Available Data African Region1 Sao Tome and Principe 1987 Zimbabwe 1990 Region of the Americas Bolivia 2003 Falkland Islands (Malvinas) 1983 Haiti 2004 South-East Asia Region1 Malaysia 2008 Sri Lanka 2006 European Region Azerbaijan 2007 Monaco 1987 Montenegro 2009 Tajikistan 2005 Eastern Mediterranean Region2 Iraq 2008 Western Pacific Region2 Kiribati 2001 Macau 1994 Mongolia 1994 1: data on most countries - except Sao Tome and Principe, South Africa, and Zambia - do not exist 2: several countries are missing, including China which was not a member at the time

Another assessment was performed in 2015 of the then 183 member states* with a population of 90,000 or above. For the purpose of defining the quality of data in the WHO Mortality Database, a classification was undertaken according to the following criteria: the presence of ICD codes or a cause list, length of time for which data are available, and average usability of data since 2000 (WHO 2017). According to these criteria, the WHO defined five categories with descending data quality ranging from more than

* By the end of 2016, 194 states were members of the WHO, others were associate members or observers. Full members have to be members of the UN as well. 8 Silke Bachmann

80% usability and availability of at least 5 years since 2005 to no usability and a high incidence of HIV. This is the basis of Figure 2. Also, the WHO reports by single countries and six regional clusters, namely the African Region, the Region of the Americas, the South-East Asia Region, the European Region, the Eastern Mediterranean Region, and the Western Pacific Region. However, suicides and injuries according to Chapter XX of the ICD-10 constituted separate categories, and just 105 countries reported injury statistics (Värnik 2012). Table 1 provides some examples of countries which have not reported suicide statistics in several years. It has to be taken into account, though, that there is no data at all from several other countries, especially in the African Region. Registering data on suicide is difficult, but determining rates of attempted suicides is much more difficult if not impossible. A suicide attempt may go unseen by anyone else and may not come to the health care system’s attention, or at least not as such.

Reprint with permission of WHO (WHO 2015a).

Figure 3. Age-standardized suicide rates per 100,000, both sexes, 2015. Perspectives of Epidemiology 9

On the other hand, suicide registration is very much desirable worldwide for reasons of prevention, detection, and intervention. Barriers to this goal are the causes mentioned above, a large variety of medical and legal issues as well as the involved authorities, or the sheer absence of medical and other personnel who are authorized to document suicides (Bertolote & Fleischmann 2002a). The lesson that can be learned from the abovementioned information is that data regarding suicide incidence across the world are in the medium to low quality range, not even speaking of suicide attempts which are estimated to be up to 30-fold higher (Wasserman 2001, American foundation for suicide prevention 2017). A broad range of causes underlie this misunderstanding or nondiagnosing, respectively -reporting. The WHO’s call for better health reporting systems becomes obvious.

THE EPIDEMIOLOGICAL PERSPECTIVE

The following information has to be looked at in the light of the knowledge concerning the quality of data in suicidology, and should thus be seen as an approximation. Nevertheless, to invoke the best possible database available, WHO data has to be cited. Figure 3 gives the distribution of suicides around the world in 2015. It is standardized for age, because age profiles differ to a marked extent between countries. Low rates (all rates per 100,000 inhabitants and in increasing order) between 0 and 4.9 were documented in Antigua and Barbuda, Barbados, Grenada, Brunei Darussalam, Brunei Darussalam, Jamaica, Bahamas, Sao Tome and Principe, Pakistan, Guatemala, Egypt, Syrian Arab Republic, Saint Vincent and the Grenadines, United Arab Emirates, Indonesia, Iraq, Venezuela, Lebanon, Algeria, Jordan, Azerbaijan, Saudi Arabia, Philippines, Honduras, Tonga, Iran, Kuwait, Tajikistan, Niger, Myanmar, Albania, Greece, Madagascar, Cyprus, and Morocco. A rate between 5.0 and 9.9 was present in Mexico, Armenia, Somalia, Bangladesh, Malawi, Panama, Afghanistan, Libya, Tunisia, Oman, Samoa, Mali, Peru, Malaysia, Vanuatu, Mauritania, Nepal, Bosnia and Herzegovina, Malta, Colombia, Senegal, Gambia, Brazil, Guinea-Bissau, Liberia, Qatar, 10 Silke Bachmann

South Sudan, Zambia, Kenya, Bahrain, Eritrea, Georgia, Dominican Republic, Saint Lucia, Ghana, United Republic of Tanzania, Uganda, Belize, Kyrgyzstan, Viet Nam, Comoros, Ecuador, Namibia, Costa Rica, Guinea, Italy, Solomon Islands, Burundi, The Former Yugoslav Republic of Macedonia, Yemen, Ethiopia, Mozambique, Spain, Fiji, United Kingdom, Cabo Verde, Rwanda, Djibouti, Maldives, Chad, Turkey, Burkina Faso, Benin, Mauritius, Seychelles, Uzbekistan, Togo, Nicaragua, Congo, Botswana, Democratic Republic of the Congo, Nigeria, Chile, and Singapore. Rates between 10.0 and 14.9 existed in Turkmenistan, China, Paraguay, Sudan, Papua New Guinea, Lesotho, Zimbabwe, South Africa, Gabon, Norway, Montenegro, El Salvador, Luxembourg, Haiti, Micronesia, Ireland, Romania, Bhutan, Australia, Cambodia, Cameroon, Netherlands, Denmark, Lao People’s Democratic Republic, Canada, Slovakia, New Zealand, Iceland, Germany, Portugal, Czech Republic, Cuba, Argentina, USA, Kiribati, Trinidad and Tobago, Swaziland, and the Republic of Moldova. The highest rates of ≥15 were found in Switzerland, Sierra Leone, Sweden, Central African Republic, India, Democratic People’s Republic of Korea (North), Bulgaria, Thailand, Finland, Austria, France, Serbia, Uruguay, Croatia, Cote d’Ivoire, Bolivia, Estonia, Japan, Russian Federation, Ukraine, Belgium, Slovenia, Hungary, Latvia, Poland, Equatorial Guinea, Belarus, Suriname, Kazakhstan, Mongolia, Republic of Korea (South), Guyana, Lithuania, and Sri Lanka.

Table 2. Suicide rates (per 100,000), both sexes, according to WHO regions (WHO 2017c)

WHO regions Crude and Age-Standardized Suicide Rates* Africa 8.8 12.8 Americas 9.6 9.1 South East Asia 12.9 13.3 Europe 14.1 11.9 Eastern Mediterranean 3.8 4.3 Western Pacific 10.8 9.1 Global 10.7 10.7 *see end of chapter for definitions.

Perspectives of Epidemiology 11

As depicted in Table 2, the highest crude or absolute suicide rate is present in the European area. It lies above the global suicide rate of 10.7 per 100,000 for both sexes. This rate has to be looked at against the background of the best quality of data being provided in Europe as well as a certain decline of suicide rates since 1980 in Western industrialized countries as a consequence of measures that have been taken (Matsubayashi & Michiko 2011). Also, assisted suicides were eliminated from the statistics in several countries, e.g., in Switzerland since 2009. Ever since the WHO started documenting suicide rates in 1950, the highest rates of suicide mortality were found in Japan in the 1950s, shifting to Eastern Europe (Hungary from the 1960s to 1980s, Lithuania from the 1990s to the 2010s), and then to Asia (Värnik 2012). Lately, China and India have been accountable for the highest contribution to suicide mortality worldwide, namely 30% of absolute numbers (Bertolote & Fleischmann 2002b). Vijayakumar et al. (Vijayakumar 2004) even claim that more than half of the suicides worldwide (54%) occur in these two countries, and South Korea may overtake all others with respect to suicide rates in a few years (Värnik 2012). WHO-collaborators expect an increase of suicides from 0,8 to 1,53 million per year in 2020 (Bertolote & Fleischmann 2002a).

Age

The highest absolute suicide numbers are present in the age group of 15 to 29 year olds, where it is the second leading cause of death after accidental deaths. In the US death statistics, suicide does not appear below the age of 10 years; in the age group 10 to 14 year olds, it presents as the third common cause of death, and moves to the second common cause in the age groups of 15-24 year olds and 25-34 year olds (National Center for Injury Prevention and Control 2015). Thus, more young people – in absolute numbers – die from suicide than elderly individuals, although rates in the elderly population are 6-8 times higher (Bertolote & Fleischmann 2002a). This compares to the WHO global data on suicide rates (per 100,000 inhabitants), 12 Silke Bachmann which are lowest in persons younger than 15 years of age, and steadily rise thereafter, reaching their highest level in individuals 70 years of age or older (WHO 2014). In addition to this global pattern regarding the young and the old, there seems to be more variability in the middle aged groups according to regions (Värnik 2012). Suicide rates rise with increasing age in most European countries and South Korea, meaning in high income countries (examples from WHO database (WHO 2016a)* include Austria, Belgium, Denmark, Estonia, Finland, France, Germany, Italy, Portugal, Spain, Sweden, and Switzerland). As Shah (2012) states, peaking suicide rates in young adults seem to be rather present in low income countries where inequality and poor access to the health care system prevail. New Zealand, although showing the same pattern (described by Shah), is not a low income country; therefore, it does not fit the paradigm (WHO 2016a) for unknown reasons. Yet, another pattern appears where suicide rates are highest in the middle-aged or elderly populations in many countries (Pitman et al. 2012, Yip et al. 2012). This is the case in the US (American Foundation for Suicide Prevention 2017) where in 2015 the highest rate was found in adults aged between 45 and 64 years (19.6) and the second highest rate in elderly individuals aged 85 years or above (19.4). Countries with a similar percentage distribution (WHO 2016a)† include Australia, Canada, Greece, Ireland, Latvia, Lithuania, Netherlands, Norway, Poland, and the UK. The African continent was also highlighted (Mars et al. 2014). Only 16 (10%) of its countries had reported mortality data to the WHO. These countries comprise 60% of the African population. Although mortality records are often incomplete and age-specific suicide rates existed for five countries only, the group summarizes the available information as follows: individuals less than 25 years of age presented the lowest suicide rates except in Ethiopia, Nigeria, Uganda, Tanzania, Zimbabwe, parts of Namibia and South Africa. Otherwise, patterns resembled the pattern of HIC with suicide rates either peaking in the younger adult or middle aged groups (e.g.,

* no or incomplete data for many countries. † no or incomplete data for many countries. Perspectives of Epidemiology 13

Seychelles, United Republic of Tanzania) or were constantly increasing (Mauritius, Zimbabwe, South Africa) (Fleischmann et al. 2005). Suicide ratios above the global ratio (10.7) were documented in Malawi, Mozambique, Seychelles, Zimbabwe (Mars et al. 2014). Fleischmann et al. (2005) studied LMIC in Asia as well. Suicide patterns resembled those in Africa with the respective divergence, and were most likely income related (Shah 2012). Data with reference to children are sparse and contradictory. Whereas Mars et al. (2014) report a rate of ≤0.5 per 100,000 in African children under 15 years of age, the Centers for Disease Control (CDC) found suicide to be the third common cause of death in Americans aged 10-14 years in 2015. Suicide did not play a role below the age of 10, but rose thereafter (National Center for Injury Prevention and Control 2015).

Gender

In 2015, almost 800,000 people died from suicide. The suicide rate amounted to 10.7 per 100,000 population with a male:female ratio of 1.7, meaning that men are almost twice as likely to deliberately kill themselves than women (WHO 2015a). The male:female ratio’s range, however, spreads out from 0.8 in Bangladesh and China to 12.2 in St. Vincent and the Grenadines, including data from 183 countries which were available in 2015 (see Figure 4). Only in Bangladesh and China was the suicide rate higher among women than men. Further countries exhibited a relatively high rate of female suicide with male:female ratios below the global rate, namely Pakistan, Brunei, the Democratic People’s Republic of Korea (North), India, Nepal, Iraq, Bhutan, Iran, Maledives, Tonga, and Tunesia (rates ranging from 1.0 to 1.6 in that given order). These countries are part of the WHO regions of South East Asia (n = 6), West Pacific (n = 3), and Eastern Mediterranian (n = 4) (WHO 2017a). Remarkably high suicides are present in young women aged 15-29 years from South East Asia, ranging into their thirties, which is 14 Silke Bachmann said to be the leading cause of death in these countries (Jordans et al., 2014). In the Western Pacific region, a peak exists for women from age 45 onwards.

Reprint from Global Health Observatory (GHO) data with permission of WHO (WHO 2015b).

Figure 4. Global male:female suicide ratio of age standardized suicide rates per 100,000 in 2015.

The highest rates of female suicides in 2015 arose in China (11.5), Angola (11.6), Japan and Belgium (12.4), Suriname (12.7), Bolivia (13.1), Sri Lanka (13.7), India (14.3), the Democratic People’s Republic of Korea (North) (15.4), Guyana (15.5), and the Republic of Korea (South) (16.4). The 10 highest male:female ratios were seen in Poland and Cyprus (6.7), Rwanda (6.9), Slovakia (7.2), the Bahamas (7.3), Belize (7.4), Saint Lucia (7.5), Seychelles (8.3), Jamaica (8.7), Panama (9.2), and St. Vincent and the Grenadines (12.2); men ended their lives up to 12 times as often as women in these countries. Male suicide rates were highest in Latvia (39.1), Poland (39.2), the Republic of Korea (South) (40.4), Suriname (40.5), Belarus (41.0), Guyana Perspectives of Epidemiology 15

(42.4), Kazakhstan (46.8), Mongolia (47.8), Lithuania (58.0), and Sri Lanka (58.7) (WHO 2017d). According to age groups, the male suicide rate in the range of 15-29 year olds was highest in the South-East Asia region, which holds also true for men aged 30–44 years, only to a lesser extent. For the 45-59 age group, the lead went to men in Europe and in the Western Pacific region aged 60 and above (Värnik 2012). Worldwide, the number of suicides by males has increased to a much greater extent as those by females since the 1990s (Bertolote & Fleischmann 2002a). Overall age distribution, but not absolute numbers are mostly similar in males and females, and they follow the pattern of their respective countries. A comparison of LMICs and HICs yields higher suicide rates in LMICs in both male and female young adults as well as in older women than in the respective groups of HICs, except for middle-aged men in LMICs (WHO 2014).

Socioeconomics

Several social influences determine the risk and course of mental disorders being the major cause of suicide. According to Patel et al. (Patel et al. 2016), these are the following groups of determinants:

1. Demographic factors: age, gender, ethnicity, and related – as discussed above. 2. Socioeconomic status: low income, income inequality, unemployment, low education, and low social support. 3. Social change: individual such as change in income, and societal such as urbanization. 4. Neighborhood: inadequate housing, overcrowding, and violence. 5. Environmental incidences: climate change, natural catastrophe, war, conflict, and migration.

16 Silke Bachmann

This list underlines why most suicides, namely 78%, occur in low- and middle income countries (WHO 2014, 2017b) and why global suicide rates have increased by 60% in the past 45 years, although in Western countries rates have roughly declined over the past 40 years (WHO 2013). Apart from the availability of care, its utilization depends on employment and education (Bhui et al. 2006). As a major example, income shall be discussed below. Unemployment, low income, and poverty are not the only human tragedies which may lead to suicide or self-harm. On the other hand, socioeconomic conditions may be consequences of suicides in terms of loss of productivity, income, and further increase of poverty in families and communities. This vicious circle exists worldwide. It is reported by a review (Bantjes et al. 2017) and single studies from different countries, including those with a high gross domestic product such as the US (Kim 2015), Canada (Tjepkema et al. 2013), Japan (Inoue et al. 2014), 29 European countries (Fountoulakis et al. 2014), Iran (Behmanehsh Poor et al. 2015), Chile (Spears et al. 2013), Sri Lanka (Knipe et al. 2017), and South and South- East Asia (Knipe et al. 2015). Unfavorable socioeconomic factors exert a higher influence in the lower income groups of the respective countries, be they – absolutely speaking – high, middle, or low income countries. Thus, inequality may be an underlying factor. Along these lines, recession shall also be discussed. A decline in a country’s gross domestic product and individual income, resp. unemployment may not represent social inequality but a major change (see 3. social change) in the personal and family sectors causing serious financial problems. Consequences of recession have been linked to increased self- harm and suicide rates by reviews (Oyesanya et al. 2015, Frasquilho et al. 2016). On a societal level, costs of suicide are high, not least because young and middle-aged men are affected, those who are at the beginning of their professional career and family planning and/or the working members and society’s towers of strength (evt. WHO 2014). Already ten years ago, the cost per suicide was rated to over $1 million in the US (Shepard et al. 2015). As opposed to this conservative estimate, other authors gave numbers Perspectives of Epidemiology 17 between $2.1 and $2.5 for Ireland, Scotland, and New Zealand (O'Dea & Tucker 2005, Platt et al. 2006, Kennelly 2007). The aforementioned literature mostly draws on high income countries; only 6% stems from low income countries, e.g., sub-Saharan Africa (Bantjes et al. 2017). Thus, although most suicides are completed in LMCI, little is known about costs generated in these countries (Bantjes et al. 2017).

Methods of Suicide

Methods of suicide differ between regions more than between countries. The most recent overview was presented in 2008 (Ajdacic-Gross et al. 2008). Authors distinguished the following methods: pesticide poisoning, other poisoning, hanging, drowning, firearms, falls, and others.

Africa According to the above authors, hanging was by far the most common method of suicide in South African males (69%) and females (41%), with poisoning with pesticides and mediciation overdose following (mostly in females) 35%. When Mars et al. reviewed the issue in 2014 (Mars et al., 2014), data from 16 of 53 African countries – including South Africa – were available and comprised about 60% of the continent’s population, mostly from large cities However, information on methods used was present from 10 countries only. The authors state that hanging and poisoning had the highest prevalences with considerable variations between countries (hanging 8% - 70%; poisoning 8% - 83%). In some countries the use of firearms was another common method (0% - 32%). Differentiations according to gender are not available.

The Americas In the US (Ajdacic-Gross et al., 2008), males most often used firearms (61%) to end their lives, while females almost equally used firearms (36%) and poisoning (31%). In most of the other American countries, firearms played a lesser role in male suicide as opposed to pesticide poisoning 18 Silke Bachmann

(ranging from 0.4% in Canada to 86% in El Salvador) and hanging (rangeing from 8% in El Salvador to 77% in Chile). Women in the Americas took their lives by poisoning themselves with pesticides (ranging from 1% in Canada to 95% in El Salvador) and by hanging (5% in Nicaragua to 63% in Chile).

Asia In Asia, hanging was the most common method of suicide (23% in Hongkong to 69% in Japan and 92% in Kuwait), but males from Hongkong – as opposed to the other countries – more frequently lost their lives to falls (43%) as well as other, non-specified methods (23%). Falls and non- specified methods also were used by females from Hongkong (48% and 23%), whereas women from other Asian countries commited suicide by hanging (26% in the Republic of Korea (South) to 60% in Japan) or pesticide poisoning (4% in Japan to 43% in Republic of Korea). Overall, poisoning and hanging were the two leading means of committing suicide in Asia (Jordans et al. 2014), but in Korea and the South-East Asian Region the prominent means were hanging and falls (Park et al., 2016).

Europe The most prevalent suicide method in males of all European countries was hanging (33% in Finland to 91% in Poland). It was the most prevalent method – except for Swiss males, who more often used firearms (34%). This goes back to the mandatory military service of several phases, in between which firearms are being taken home. The use of firearms presented 21-27% of male suicide methods in males in Austria, France, Croatia, Finland, and Norway. Falls were a relevant method of suicide in Spain, Luxembourg, and Malta (18-22%), whereas other non-specified methods played a role in the Netherlands, Denmark, the UK, Iceland, and Georgia (20-33%). European women most commonly used hanging (15% in Luxemberg to 83% in Lithuania) and also poisoning (presumably with medication; 7-43%). In Luxemburg, Spain, and Malta, falls were a frequent method of suicide used by women (29%, 37%, and 57%). Poisoning with pesticide reached relevant numbers in Moldova and Portugal (18% and 24%). In Georgia, only other non-specified reasons ranked high in women (34%). Perspectives of Epidemiology 19

Australia and New Zealand Men used hanging (45%, 48%) most often, followed by other methods (both 29%) and firearms (12%, 11%). Likewise, women used hanging most commonly (36%, 43%) followed almost equally by other, non-specified methods (25%, 24%) and poisoning (27%, 20%). No data were available from the Western Pacific Region. A recent paper focuses on suicide methods in children and adolescents worldwide, encompassing 101 countries and regions. Authors conclude that methods compare to those of adults in the respective countries (Kõlves & de Leo 2016). Across all countries, regions, age groups, and gender, hanging was the most common method of suicide followed by poisoning (30%) and firearms. With respect to fatality, firearms rank highest (83%), followed by drowning (66%) and hanging (61%), by gas poisoning (42%), falls/jumps (35%), poison ingestion (1.5%), cutting (1.2%), and other methods (8%) (Spicer & Miller 2000).

Special Groups

Several groups and aspects require special attention because they may influence the overall picture. Higher suicide rates were present in refugees and asylum seekers (Lindert et al., 2008, Kalt et al., 2013), homeless people (Fekadu et al., 2014)), police, firefighter, and other first-line responders (Milner et al., 2017) as well as individuals in the army (Gradus et al., 2012, Nock et al., 2014). Research on migrants, however, yields diverging results. On the one hand, a European study states that immigrants “bring along their suicide risk”, thus keeping the risk of their country of origin (Spallek et al., 2014). Further studies yielded contradictory results: Irish born had significantly higher suicide rates in London (Ougrin et al., 2011), whereas a study on immigrants to Australia even found a decline in the suicide risk (Kõlves & De Leo 2014), which may depend on a better socioeconomic situation (Law 20 Silke Bachmann et al., 2013). Overall, immigrants and minorities seem to be at higher suicide risk (McSpadden 1987, Bauwelinck et al., 2017). Country of origin, ethnicity, and country of settlement play a role (Singh & Miller 2004, Garssen et al., 2006, Lipsicas & Mäkinen 2010, Honkaniemi et al., 2017) as well as the time spent in the country of settlement and possibly intergenerational conflicts triggered by differences between the old and new culture (Lipsicas & Mäkinen 2010).

Reprint with permission of WHO (WHO 2014a).

Figure 5. Key risk factors for suicide aligned with relevant interventions (size of lines reflects the relative importance of interventions) Perspectives of Epidemiology 21

A number of reviews have found an increased risk of suicide among transgender, lesbian, gay, and bisexual people (Haas et al., 2011), with high rates of suicide attempts in transgender individuals ranging between 30 and 50% across countries (Virupaksha et al., 2016). Suicide rates are also linked to incarceration (see Chapter Two of this book). In residents of high security hospitals, men’s rates are 7 times and women’s are 40 times higher compared to the general population (Jones et al., 2010). Further influences on suicide rates are associated with geography (e.g., the amount of daylight) (Petridou et al., 2002, Hiltunen et al., 2011, Benard et al., 2015), physical disease (see below), copycat suicide, the so-called “Werther effect” (Schmidtke & Häfner 1988, Etzersdorfer et al., 2004, Sisask & Värnik 2012), manmade factors such as legislation on suicide (e.g., suicide is illegal in Ghana, Kenya, South Sudan, Tanzania, Uganda, Bahamas, Bangladesh, Brunei, Jordan, Lebanon, Malaysia, North Korea, Oman, Pakistan, Saudia Arbia, Singapore, Syria, United Arab Emirates, Yemen, Cyprus, and Papua New Guinea; the situation is unknown in many other countries) (wikipedia 2017), forced marriage, domestic violence, stigmatization of sexual minorities (Vijayakumar et al., 2015), and many more (see Figure 5).

Religion

According to Bertolote (Bertolote et al., 2005), belief plays an important role when someone decides to end his/her life. Whereas in Muslim countries hardly any suicides occur (as it is forbidden), in countries where Hinduism or Christianity are still prevailing, rates range around 10:100,000 (e.g., India 9.6, Italy 11.2). In Japan, where Buddhism shaped society, the suicide rate amounts to 17.9% and to 25.6% in atheistic China. The cited studies did, however, not collect information about the meaning of religion to the individual (Bertolote & Fleischmann 2002a).

22 Silke Bachmann

Suicide Attempts

Data on suicide attempts is of low quality. There is no reliable statistics available due to the abovementioned caveats (see “Quality of Data”), which applies to suicide attempts much more than to completed suicides. No single country in the world provides information on attempted suicides to the WHO (Lee et al., 2017), although self-reports and data from somatic hospitals/ emergency rooms should be available (Patel et al., 2016). Nevertheless, there is general agreement that attempts occur up to 30 times as often as completed suicides (Wasserman 2001, American Foundation for Suicide Prevention 2017). Figures up to 100-200 attempts per suicide in young adults from 15-24 years of age have been mentioned by the US CDC (Center of Disease Control 2012). Completed suicides are higher in men, whereas suicide attempts are 2-3 times higher in women. Moreover, there is an effect of risk factors such as being young, divorced or widowed (Weissman et al. 1999, Bernal et al. 2007). Underlying psychiatric problems as well as methods used do not seem to differ between suicide attempts and completed suicides. The risk to die, however, increases with the number of previous suicide attempts (Patel et al., 2016), and suicide attempts are the most relevant predictors of complete suicides (WHO 2014).

Prevention

Preventive measures can have an impact on suicide rates, and communities and countries may effectively decrease suicide rates by implementing primary and secondary prevention. Respective effects have been shown in several high income countries which experienced a drop in suicide rates – e.g., in Germany between 1990 and 2010. Thereafter, Japan and South Korea were left with the highest rates among the high income countries. Both governments gave out plans for the prevention of suicide (e.g., a 5 year plan in South Korea, 2011) (Korea 2011) and have since also Perspectives of Epidemiology 23 witnessed decreases (Statistica 2017a, Statistica 2017b) by identifying vulnerable groups and supporting protective parameters. Altogether since the year 2000, 28 countries have implemented national prevention strategies, which include several and varying means of primary and secondary prevention. These programs are distributed among the WHO regions as follows: Europe 13, Americas 8, Western Pacific 5, South-East Asia 2, and Africa and Eastern Mediterranian 0 programs (WHO 2014).

Primary Prevention Prevention usually starts with a survey, in this case self-reports on suicidal behavior, which can help a country to create its own data base and deduce its further needs, e.g., the MONSUE study (The MONSUE Consortium 2010). A relatively simple way of primary prevention is the reduction of access to means of suicides. Once there is less or no access to poison and potentially poisonous medication like paracetamol, bridges, firearms, and railways, suicide rates drop. This has been the case when barriers were established at the Golden Gate Brigde in San Francisco, the Empire State Building in New York City, and the Eiffel Tower in Paris (O’Carroll et al., 1994) or when access to firearms was reduced (Lubin et al., 2010). The effectiveness of such measures was also shown in a study in 21 OECD countries (Matsubayashi & Michiko 2011). Other, more costly means are the establishment of community awareness programs including public education, workplace, and school based interventions encompassing teaching and stigma reduction, and helplines. Non-health professionals, who are gatekeepers, such as teachers, clergy, and first-line responders should be involved and trained. Access to care and availability of crisis intervention is important for those seeking treatment, as was documented in Hungary and Ex-Yugoslavia/ Slovenia (Rihmer et al., 1993, Jagodič et al., 2013). In both countries there was a negative correlation between the number of physicians or psychiatrists and the respective suicide rate which changed once the number of professionals grew. This was the most important preventive measure followed by the rate of individuals treated for depression. 24 Silke Bachmann

In LMIC, the involvement and training of non-specialized health professionals regarding assessment and management of suicidality is of utmost importance due to limited professional resources. The same holds true for the primary care sector worldwide (Soubrier 2001, WHO 2010). Where health care resources are present, namely in HIC, the individual who later completed suicide had been in contact with a physician or even a mental health carer during the year preceding suicide (Pirkis & Burgess 1998, Jason B. Luoma et al., 2002). Trained volunteers are of considerable help as well, e.g., as online and telephone counsellors (Coveney et al. 2012). Meanwhile, volunteer counsellors are reknowned globally for providing instant support (Mishara et al., 2007). Moreover, self-help groups for survivors of suicide attempts and for bereaved relatives have grown in numbers and importance since 2000 (De Leo et al., 2014). The media should be encouraged to change policies and reporting practices in order not to stimulate copycat suicides; ideally, appropriate guidelines or policies are implemented (Niederkrotenthaler et al., 2012, Sisask & Värnik 2012). To this end, the WHO has published a useful source for journalists (WHO 2017f).

Secondary Prevention The health care system plays the most important role regarding secondary prevention. After a suicide attempt, 22% to 88% of individuals present to primary care or to a hospital; the number depends on cultural characteristics (Bertolote et al., 2005a). As a consequence, gatekeepers, health workers, and primary care physicians have to be trained to ameliorate their capacity to assess and manage suicide attempts as well as deliver adequate intervention and follow-up, respectively, and initiate transfer to appropriate care. Unfortunately, hospital-based surveillance systems for suicide attempts are still missing in most LMIC (WHO 2016b); they are present in Europe and have been evaluated (The MONSUE Consortium 2010).

Perspectives of Epidemiology 25

The Social Media Perspective

Meanwhile, social media plays an important role internationally, but information of its use is mainly available in English, thus reflecting the use in HIC or in the upper social strata of LMIC. On the one hand, individuals who seek help may find abundant sources of information on where to obtain support. On the other hand, however, those who look for pro-suicide websites and suicide pacts in blogs or chatrooms will also find plenty of instructions (Ozawa-de Silva 2008, Durkee et al., 2011, Lee et al., 2017). Thus, the Internet is a potent, but Janus-faced source of information. Interesting information is available from Google and can be found on the website “Our World in Data” (Lee et al., 2017). The engine’s function “trends” allows to study users’ search behavior with respect to specific terms. By plotting searches concerning “suicide help”, “how to suicide”, and “how to overdose”, obvious positive associations arose between those requests. Apparently, possibilities of good and harmful Internet use call for installing further measures of prevention such as barriers to pro-suicide sites and awareness campaigns. Assisted suicide is not included in this chapter, nor is extended suicide due to a lack of literature.

THE DISEASE PERSPECTIVE

The prevalence of suicide attempts and suicides is significantly increased in the context of mental or physical health problems. Both shall be discussed separately.

Mental Health

Death from suicide is about 10 times as high in individuals suffering from a mental health problem than it is in the general population. Numbers

26 Silke Bachmann for suicide rates connected to a diagnosable mental illness at the time of death amount up to at least 90% (Chang et al., 2011, Röcker & Bachmann 2015). A study by Bertolote et al. (Bertolote et al., 2004) reviewed the available literature on suicide with respect to psychiatric diagnoses. Data of 15,629 deceased individuals were included in the study, unfortunately with limited representativeness: 82% of data stemmed from Europe and North America. A diagnosable mental disorder was present in 98%. Out of all cases reviewed, 7,424 (47.5%) had been admitted to a psychiatric inpatient service at least once. Globally, in the beginning of this century, depression was the psychiatric disease with the highest excess mortality of unnatural cause (30%) followed by substance-use related disorders (18%), schizophrenia (14%), and personality disorders (13%) (Bertolote et al. 2004). In- and outpatients’ diagnoses differed: almost half of inpatient suicides (45%) were related to serious diseases like schizophrenia and organic mental disorders in inpatients, whereas substance-related, somatoform, anxiety, and adjustment disorders preceded suicides by community dwelling patients (32%). Only depression prevailed in both groups, although suicide rates differed (Bertolote et al., 2003). Globally and among the general population, namely in outpatients, 54% of those who died by suicide had been diagnosed with depression. More severely depressed individuals were admitted to inpatient care, their suicide rates were higher than those of outpatients and amounted to 21%. Numbers from a Swedish 22 year national cohort ranged from 12 to 19% of depressed inpatients who die from suicide (Ösby et al., 2001) compared to the global data. (Bertolote et al., 2004). Walsh et al., (2015) reported an overall suicide rate of 147 per 100,000 inpatient years. According to this meta-analysis, suicide rates of inpatients increased during the past years and were related to the general population’s rate, as well as to shorter stays in hospital. Numbers from single studies range from 76 per 100,000 admissions in Germany (Hübner-Liebermann) to 116/167 (women/men) in a Japanese study (Fujita & Kurisu 1992), and to

Perspectives of Epidemiology 27

368 in a study from Australia covering a duration of 21 years (Ganesvaran & Shah 1997). While a lifetime suicide risk of 8.6% was reported in patients who had ever been admitted to a psychiatric inpatient treatment (Chang et al., 2011), a very recent study even concluded that inpatient-status by itself may constitute one of the highest risk factors toward suicide (Large et al., 2017). Interestingly, German authors reported that 75% of inpatient suicides were completed outside the psychiatric hospital using violent methods. Most of these patients had been given permission to leave the ward (Hübner- Liebermann et al., 2001). The first weeks after a patient’s discharge deserve special mentioning as suicide rates increase within one, respectively three months after discharge from inpatient treatment facilities (Goldacre et al., 1993, Geddes et al., 1997, Isometsä et al., 2014, Chung et al., 2017). Male gender and previous suicide attempts increased the risk of post- discharge completed suicides in Finland (Isometsä et al., 2014). Other authors found that a diagnosis of schizophrenia, a longer stay in hospital, and previous suicide attempts represent risk factors as opposed to suicidality prior to the index-admission (Hübner-Liebermann et al., 2001). Less is known regarding suicide rates of out-patients when compared to in-patients. The psychiatric diagnoses may be unclear, unknown, or omitted in the death certificate, and suicide may not be recognized as such (Fujita & Kurisu 1992).

Selected ICD-10 Diagnoses and Suicide

ICD-10 F0 Organic mental disorders are said to be 10 times as high in suicide completers with former inpatient status compared to those from the general population (Bertolote & Fleischmann 2002b). Most notably, dementia patients seem to be at least at moderate risk (Kim & Hyun 2013, Sabodash et al. 2013, Fonseca & Machado 2014, Richard-Devantoy et al., 2014, Koyama et al., 2015, Serafini et al., 2016) including pre-emptive suicide (Davis 2013, Dresser 2013). 28 Silke Bachmann

ICD-10 F1 Substance use disorders are explicitly listed in chapter F1 of the ICD- 10, thus labeling them as “mental disorders”. By speaking of mental and substance use disorders the literature on suicide creates confusion (Whiteford et al., 2013, Ferrari et al., 2014). Outside psychiatric wards, substance-related disorders constitute the second most frequent (22.4%) cause underlying suicide. The problem is already present in 12-18 year-olds. In inpatients, the incidence doubles. Among all substances alcohol is the frontrunner (Driessen et al., 1998, Darvishi et al., 2015, Park & Kim 2016). Cultures with a permissive attitude towards alcohol may have to deal with a higher suicide rate, meaning that anybody who has ever been treated for alcoholism faces a 2-3.4% increased risk of suicide. Male gender, older age, and previous suicide attempts constitute further risk factors in alcohol abuse (Sher 2006, Vijayakumar et al., 2011, Hung et al., 2015). The even higher risk in adolescence may be mediated by alcohol-related neurological and psychological dysfunctions (Sher 2007). Moreover, alcohol seems to facilitate the use of other drugs and suicide by other methods including illicit drugs (Conner et al., 2013, Kennedy et al. 2015). Special attention has to be paid to alcohol intoxication, which in itself clearly leads to an increase in suicidality including completed suicides, and to alcohol intoxication related to adjustment disorders (e.g., bereavement) and depression (Wetterling & Schneider 2013). This compares to chronic use of and intoxication with other substances (Fadem 2004, Vijayakumar et al., 2011). However, as far as the absolute influence of substances is concerned, most suicides are completed after intake of alcohol and/or sedative-hypnotic drugs in individuals, 40-85% of whom are not dependent (Youssef & Rich 2008, Vijayakumar et al., 2011). Prescribed medication like benzodiazepines are involved in suicides, the rate of prescriptions being unclear. Withdrawal symptoms, however, seem to play a role (Youssef & Rich 2008, Dodds 2017). Heroin correlates with a 14-fold increase of death from suicide; studies found that up to 35% of deaths in heroin consumers occurred unnaturally

Perspectives of Epidemiology 29

(Darke & Ross 2002). Cocaine, cocaine withdrawal, and methamphetamine lead to considering suicide in about two-thirds of users and to attempts in 20%, whereas cannabis probably is not related to an independent increase of risk (Ayd 2000, Darke et al., 2008, Vijayakumar et al., 2011). Vice versa, 40% of individuals who present for treatment of substance dependence have attempted suicide in the past (Yuodelis-Flores & Ries 2015). Some authors even report a certain suicide risk related to smoking cigarettes (Hughes 2008). Overall, there is frequent co-occurrence of substance misuse and other mental disorders (Vijayakumar et al., 2011). When substance use, especially cannabis use, clearly precedes major mental illness – an earlier disease onset has been described mainly in schizophrenia and bipolar disorder –, it does not raise an exception in other disorders (Donoghue et al., 2014, Leite et al., 2015).

ICD-10 F2 Schizophrenia is the second most frequent diagnosis related to suicide in inpatients (20%), and the amount in outpatients is about half of this (Bertolote 2002). Overall suicide rates range from 5 to 14%, but authors assume that true numbers are located on the upper end (Bertolote et al. 2004, Pompili et al. 2007, van Os & Kapur 2009). Suicide attempts occur in about 10% of patients during the first year of treatment (Nordentoft et al. 2015) with an even higher risk of attempts and completed suicides in adolescents, such as in early onset schizophrenia (Remschmidt & Theisen 2012). The overall risk also increases with depressive and hallucinatory symptoms (Bagaric et al. 2013, Kjelby et al., 2015). Other groups confirmed several additional factors of negative influence, namely male sex, high premorbid IQ, anxiety, feelings of guilt, history of a suicide attempt, non-suicidal self- harm, number of psychiatric admissions, period following psychiatric inpatient treatment, closeness to illness onset, treatment delay, and substance abuse (Gomez-Duran et al., 2012, Jovanovic et al., 2013, Mork et al., 2013, Popovic et al., 2014, Weiser et al., 2015).

30 Silke Bachmann

ICD-10 F3 Mood disorders, especially major depressive disorders account for about half of all deaths from suicide; the suicide risk is increased by 20 times compared to healthy subjects (Ösby et al. 2001, Lépine & Briley 2011). Thus depression is the leading cause of suicide worldwide and second with regard to all years lived with disability (up to 11% globally) (Ferrari et al. 2013, WHO 2015). In almost all countries severity of depression is related to treatment probability. However, Lépine and Briley stated that up to 50% of depressed individuals in high income countries and up to 85% in LMIC remained untreated during a 1-year-period (Lépine & Briley 2011). Whereas depression-related suicides – including a considerable share of depression with psychotic symptoms – prevails in the elderly (Ganguli et al. 2002, Vythilingam et al., 2003), suicide attempts (up to 42%) and suicides in bipolar disorder are associated with the first depressive episode occurring around the 25th year of life. The use of illicit drugs, especially of cannabis may push forward disease onset and thus suicidality by up to 6 years and increase suicidality to 60% (Leite et al., 2015). Further variables related to suicide deaths in bipolar disorder are male gender and a first-degree family history of suicide. Suicide attempts are significantly related to younger age at illness onset, female gender, depressive polarity of the first, current or most recent episode, any substance or alcohol use, and comorbidities such as anxiety disorder or cluster B personality disorders (Schaffer et al., 2014).

ICD-10 F4 Mortality from suicide related to anxiety disorders ranges from 2.5% in inpatients to 6% in the general population (Bertolote & Fleischmann 2002b). Although there even is a moderate increase in suicide associated to obsessive-compulsive disorder (Angelakis et al., 2015), posttraumatic stress disorders (PTSD) deserve special mentioning among the diagnoses in this chapter. Not only is there a rise in the incidence of PTSD worldwide through wars, terrorism, migration and the like, but co-morbidities are the rule rather than the exception (Sareen et al., 2005, Cougle et al., 2009a, Chang et al. 2011, Panagioti et al., 2012, Lee, D. J. et al., 2014). The rate of suicidality Perspectives of Epidemiology 31 reaches approximately 20% in this population, and even higher numbers in adolescents (Cougle et al., 2009b, Wherry et al., 2013, Selaman et al., 2014, LeBouthillier et al., 2015).

ICD-10 F5 In this ICD-10 chapter, eating disorders represent the group with the highest suicide risk (Tintinalli 2010). For example, in a study following patients after hospital discharge, the standard mortality ratio amounts to 7.8 for all eating disorders in the age group 15-24 years, to 11.5 in anorexia nervosa and 4.1 in bulimia nervosa. In adults aged 25-44 years of age, this NHS data based study alludes to a mortality rate of 10.7 for all eating disorders, 14.0 for anorexia nervosa, and 7.7 for bulimia nervosa (Hoang et al., 2014).

ICD-10 F6 Personality disorders also constitute a group of conditions with a high risk of suicide, they account for 15% of inpatients and for almost 12% of suicides in the general population (Bertolote & Fleischmann 2002b, Bertolote et al. 2004). Within this group, borderline personality disorders are the most common diagnoses leading to suicide, the rate being estimated to 3-9% (Bertolote et al., 2004, Lieb et al., 2004, Pompili et al., 2005, Stone 2016). Additionally, so-called chronic suicidality poses a special challenge (Lieb et al., 2004, Paris 2004, Goodman et al., 2011). According to Ansell et al. (Ansell et al., 2015), the narcissistic personality disorder is second among the personality disorders regarding suicidality. The literature mentions suicide attempts and completed suicides (Dammann & Gerisch 2005, Heisel et al., 2007, Blasco- Fontecilla et al., 2009, Pincus et al., 2009). Narcissistic personality disorders like all other single diagnoses are related to less than 5% of suicides each.

Comorbidities In all mental disorders the risk of suicide increases with each single comorbidity. The highest risk was observed in combination with psychotic disorders (a rise of 50% in inpatients), followed by mood disorders 32 Silke Bachmann combined with substance abuse or personality disorders (Bertolote & Fleischmann 2002b, Hansen et al., 2003, Buckley & Brown 2006). To summarize, diagnoses underlying suicide in outpatients/individuals from the general population are mood disorders, substance abuse, personality disorders, and anxiety and adjustment disorders including PTSD, whereas the most common diagnoses in inpatients are mood-disorders, schizophrenia, and organic mental disorders. Comorbidities play an important role, and each comorbidity increases the suicide risk (Pallanti et al., 2006, Hansen & Rossow 2008, Oliveira et al., 2008).

Physical Health

Suicidality is related to a number of physical illnesses as well. In this context, potentially lethal disorders like cancer and HIV-infection are named frequently. A diagnosis of cancer doubles the suicide risk, independently of further comorbidities such as depression and substance-use disorders (Allebeck et al., 1989, Anguiano et al., 2011, Lee. et al., 2014). As opposed to the studies on cancer, the association of HIV-infection and suicide was mostly studied in LMIC (Keiser et al., 2009, Schlebusch & Vawda 2010, Guimaraes et al., 2014, Schlebusch & Govender 2015). Almost any chronic disease may lead to an increase of suicide risk; hemodialysis for kidney failure, asthma, multiple sclerosis, systemic lupus erythematodes, and epilepsy represent examples (Tintinalli 2010, Pompili et al., 2012, Chung et al., 2016, Tian et al., 2016, Tsigebrhan et al., 2017). Moreover, suicidality rises with disabilities (Rahman et al., 2014) such as traumatic brain or spinal cord injury (Simpson & Tate 2007, Khazaeipour et al., 2015), and post-stroke conditions (Eriksson et al., 2015). Recently, a surge of suicidality has been reported following bariatric surgery (Backman et al., 2016, Kovacs et al., 2016). As in mental illness, suicide risk rises with every additional medical condition, and health problems may even range among the major reasons for suicide (Yip 2008). Along these lines, an 8-fold increase of suicides compared to the general population in a Taiwanese general hospital was reported (Tseng et al., 2011). Perspectives of Epidemiology 33

Chronic Pain Chronic pain represents a special condition. As there is a considerable overlap of chronic pain and depression with unclear causality (Fishbain et al., 1997), the condition may be either looked at physical disease or as a somatoform, namely a mental disorder, or as a physical disease. The prevalence of chronic pain is high (data from HIC amount to 10-55%) (Harstall & Ospina 2003) and is associated with a 2-3 times increased rate of suicides as compared to controls, and an even higher number of suicide attempts (Tang & Crane 2006, Campbell et al., 2015). This holds true even when mental illness is accounted for (Ratcliffe et al., 2008).

SUMMARY

In summary, suicides are completed at higher-than-average rates in young males (ages 15-49); in elderly people, especially elderly males; in indigenous people; in individuals in custody; in those with previous suicide attempts; and especially in people with mental illnesses, including alcohol and/or substance use. Suicide attempts are even up to 30 times higher than completed suicides. The presumably pronounced extent of non- or underreporting leads to a low quality of data. Suicide rates are subject to change because they depend on many environmental, social, cultural, and economic factors. As a consequence, suicidality is not just a health care issue, and it should be given high priority in many political and social spheres to try and prevent it.

ABBREVIATIONS AND EXPLANATIONS

DALY disability adjusted life years = the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability GHE global health estimate HIC high income countries 34 Silke Bachmann

LMIC low and middle income countries Crude suicide Number of suicide deaths in a year (and a rate: geographic area), divided by the population (in this area) and multiplied by 100,000 Age- a weighted average of the age-specific suicide rates per standardized 100,000 persons, where the weights are the proportions of suicide rate persons in the corresponding age groups of the WHO standard population (WHO 2017c) YLD years lived with disability

ACKNOWLEDGMENTS

The author would like to thank Nadine Kenj, MD, who proofread the manuscript, for her very valuable help.

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BIOGRAPHICAL SKETCH

Silke Bachmann

Affiliations: University of Halle (Saale), Germany – Associate Professor of Adult Psychiatry. Clienia Littenheid AG, Littenheid, Switzerland – Medical Director

Education: Universities of Bonn, Heidelberg (Germany), University of Kentucky (USA) MD, doctorate, and “Habilitation” (degree necessary for professorship) form University of Heidelberg

Business Address: Psychiatric Hospital Clienia Littenheid AG, 9573 Littenheid, Switzerland

Research and Professional Experience: University of Heidelberg 1992 – 2005 Center for Psychosocial Medicine Specialist in Adult Psychiatry Specialist in in Child and Adolescent Psychiatry Research on First Episode Schizophrenia 54 Silke Bachmann

Responsibility for the education of medical students University of Halle (Saale) 2006 – 2011 Deputy Director, Dpt. of Psychiatry, Psychotherapy, Psychosomatics Head of Section Psychosomatic Medicine Research on Neurological Soft Signs

Professional Appointments: Associate Professor in Adult Psychiatry, University of Halle (Saale), 2013 – Ongoing Medical Director, Clienia Littenheid AG, Adult as well as Child and Adolescent Psychiatry (233 inpatients, 3 outpatient services, all ages and diagnoses) Teaching of medical students and residents in Psychiatry and Psychotherapy in Zürich and East of Switzerland

Publications from the Last 3 Years:

Bachmann S., Schröder J. Neurological soft signs in schizophrenia: An Update on the State-versus Trait-perspective. Front. Psychiatry, 08 January 2018 | https://doi.org/10.3389/fpsyt.2017.00272 Herzig DA, Bachmann S. Cannabis and Clubbing: Relevance of Cannabis and Polydrug Use in the Clubbing Culture Today. 2017. In: V.R. Preedy (ed.): Handbook of Cannabis and Related Pathologies. London, San Diego, Cambridge, MA, Oxford: Academic Press, pp. 171-9. Bachmann S, Degen C, Geider FJ, Schröder J. Neurological soft signs in the clinical course of schizophrenia: results of a meta-analysis. Front Psychiatry. 2014; 5:185. doi:10.3389/fpsyt.2014.00185. Röcker S, Bachmann S. [Suicidality in mental illness – prevention and therapy]. Ther Umsch. 2015 Oct; 72(10): 611-7. doi: 10.1024/0040- 5930/a000727. Bachmann S. [Coping with chronic disease]. Praxis (Bern 1994). 2014 Mar 26; 103(7): 379-84. doi: 10.1024/1661-8157/a001605.