The Most Common Method of Suicide in Tehran 2000–2004

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Article in Crisis The Journal of Crisis Intervention and Suicide Prevention · February 2008 DOI: 10.1027/0227-5910.29.3.164 · Source: PubMed

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The user has requested enhancement of the downloaded file. M. Razaeian et al.: Method© 2008 ofCrisis Suicide Hogrefe2008; in Tehran Vol.& Huber 29(3):164–166 2000–2004 Publishers Short Report The Most Common Method of Suicide in Tehran 2000–2004 Implications for Prevention

Mohsen Razaeian1,2, Maryam Mohammadi2, Malihe Akbari2, and Maryam Maleki2

1Social Medicine Department, School of Medicine, Rafsanjan University of Medical Sciences 2Public Health Department, School of Health, Shaheed Beheshti University of Medical Sciences, both Tehran, Iran

Abstract. The likelihood of completing suicide depends to some extent on knowledge of effective means and also on the availability and/or acceptability of such methods. Since studying suicide methods may have an implication for prevention, the focus of this study was on the most favored method of suicide in Tehran, Iran. The study uses confirmed suicide data provided by the Beheshet Zahra Organization (BZO), which gathers all mortality data within Tehran and enters them into a computerized database, from which the relevant information for all the recorded suicide cases during the year 2000 to 2004 were obtained and analyzed. There were 703 cases of suicide (632 males and 71 females) in the BZO database, with a sex ratio of 8.9. The mean (standard deviation) of age at suicide for those who chose hanging and for those who have chosen other methods of suicide were 33.93 (14.2) and 34.60 (13.4) years, respectively. Hanging was the method favored by 572 (85.9%) of cases. Use of hanging was higher in females (61, 85.9%) than in males (511, 80.9%), and higher among the married (304, 53.6%) than among singles (268, 46.4%). The high proportion of persons using hanging as a method of suicide in Tehran may reflect the fact that this method is more acceptable and/or easily available and/or less likely to be misclassified as accidental or undetermined death. The prevention of such suicides is extremely difficult in the general population. Therefore, it is suggested that, to prevent suicide by hangings, the authorities should focus on the causal factors of suicide rather than on the acceptability and/or the availability of this method.

Keywords: suicide, hanging, Tehran

Background “softer” methods, i.e., overdosing with medicines, while males usually select “harder” methods, i.e., hanging (Depart- The likelihood of suicidal behavior ending in death de- ment of Health, 2005). In contrast, suicide by very hard meth- pends to some extent on knowledge of effective means and od such as self-immolation is more practiced by females in also on the availability and/or acceptability of such meth- the developing countries such as India (Adityanjee, 1986) ods (Kelly, & Bunting, 1998; Department of Health, 2005). and some parts of Iran (Janghorbani & Sharifirad, 2005). As a result, there seems to be different preferences for Moreover, research has also shown that restricting access methods of suicide in different parts of the world. Gener- to some methods of suicide may have an implication for pre- ally speaking, in the United States firearms account for vention. For instance, in the 1960s there was a marked de- nearly two-thirds of all suicides, (Centers for Disease Con- crease in suicide rates in England and Wales partly due to the trol and Prevention, 2000), while ingesting pesticides is the detoxification of the domestic gas supplies (Kreitman, 1976). most common method in China (Yip, 2001), and in other However, in both sexes the effects of these reductions on countries of the word such as Greece (Zacharakis, Madia- overall suicide rates were partially compensated by an in- nos, Papadimitriou, & Stefanis, 1998) and Italy (Guaiana, crease in drug overdose (method substitution) in younger age D’Avanzo, & Barbui, 2002) hanging is more common. groups (Gunnell, Middleton, & Frankel, 2000). Apart from this general pattern, it seems that there are also Because studying suicide methods (aside from revealing age and sex preferences within each country for selecting socio-cultural preferences in selecting the methods) may suicide methods. For instance, females in the more developed have implications for prevention, this study focuses on the world such as England and Wales have a tendency to select most favored method of suicide in Tehran, the capital of

Table 1. Distribution of cases by gender and methods of Table 2. Distribution of cases by marital status and methods suicide of suicide Method Method Other Hanging Total Other Hanging Total Gender Male Count 121 511 632 Marital Single Count 58 268 326 % 19.1 80.9 100 status Female Count 10 61 71 % 17.8 82.2 100 % 14.1 85.9 100 Married Count 73 304 377 Total Count 131 572 703 % 19.4 80.6 100 % 18.6 81.4 100 Total Count 131 572 703 χ² = 1.078, df =1,p = .299. % 18.6 81.4 100 χ² = 0.285, df =1,p = .593. Iran. It should be noted that a recent study has shown that in the year 2001 the rates of suicide in Tehran were for Table 3. Distribution of cases by age groups and methods males 4 and females less than 1 per 100000, respectively of suicide (Moradi & Khademi, 2002). Method Other Hanging Total Age 10–29 Count 16 65 81 Methods group % 19.8 80.2 100 This study uses confirmed suicide data (ICD-9 codes 20–29 Count 37 208 245 E950–E959; World Health Organization, 1978), provided % 15.1 84.9 100 by the Beheshet Zahra Organization (BZO), the body re- 30–39 Count 36 118 154 sponsible for gathering all mortality data within Tehran and % 23.4 76.6 100 entering them into a computerized database. This database, 40–49 Count 26 105 131 however, does not include undetermined deaths (ICD-9 % 19.8 80.2 100 codes E980–E989; World Health Organization, 1978). Fur- ≥50 Count 16 76 92 thermore, the methods of suicide are recorded in the data- % 17.4 82.6 100 base only as either hanging or other. The age, gender, marital status, and the methods of suicide for all the recorded Total Count 131 572 703 suicide cases during 1379 to 1383 Iranian calendar time, % 18.6 81.4 100 roughly correspond to 2000 to 2004 Western calendar time, χ²= 4.588, df =4,p = .332. were obtained and analyzed using SPSS version 12. different age groups. The difference between the age groups was not statistically significant. Results

There were 703 cases of suicide (632 males and 71 females) Discussion in the BZO database, with a sex ratio of 8.9. Hanging was the method most favored by 572 (85.9%) of the cases. The The study shows that the most favored method of suicide mean (standard deviation) of age at suicide for those who chosen by females and males within Tehran was hanging, chose hanging and for those who chose other methods of which accounted for 85.9% of all suicides in the sample – suicide were 33.93 (14.2) and 34.60 (13.4) years, respec- among the highest percentages in the world. In Italy some tively. However, the difference between two means was not 40% of suicide cases in 1996 used hanging (Guaiana et al., statistically significant. Furthermore, the median age at sui- 2002), while in Greece hanging was employed in approxi- cide for hanging and other methods of suicide was 30 and mately 50% of suicides during the period of 1980 to 1995 33 years, respectively. (Zacharakis et al., 1998). A higher proportion of women 61 (85.9%) chose suicide The higher proportion of females choosing hanging in by hanging than men 511 (80.9%), but the data were not Tehran (85.9%) in comparison to males (80.9%) is another statistically significant (Table 1). More singles 268 (82.2%) important finding of this study. This figure is higher than died by hanging than married persons 304 (80.6%), which reported figures for other countries. In the year 2003 hang- was also not statistically significant (Table 2). Table 3 ing accounted for 46.1% of all male suicides in Britain. shows the difference in the proportion using hanging in the Among British females hanging was the second most com-

mon method of suicide, accounting for 25.6% of all female Centers for Disease Control and Prevention. (2000). National in- suicide deaths (Department of Health, 2005). jury mortality reports, 1987–1998. Atlanta: Author. The findings of the present study may reflect that, for Department of Health. (2005). National Suicide Prevention Strat- those people who died by suicide in Tehran, egy for England. Annual Report on progress 2004. London: 1. hanging is more culturally acceptable and/or Stationery Office 2. hanging is more easily available and/or Guaiana, G. D’Avanzo, B., & Barbui, C. (2002). Update of suicide trends in Italy from 1986 to 1996. Social Psychiatry and Psy- 3. hanging is less likely to be misclassified as accidental or chiatry Epidemiology, 37, 267–270. undetermined death especially for females. Gunnell, D., Bennewith, O., Hawton, K., Simkin, S., & Kapur, N. (2005). The epidemiology and prevention of suicide by hang- What would be the implications of these results for the pre- ing: a systematic review. International Journal of Epide- vention of suicides in Tehran? Hanging is a relatively lethal miology, 34, 433–442. method of suicide with a case fatality rate over 70% (Simou- Gunnell, D., Middleton, N., & Frankel, S. (2000). Method avail- net & Bourgeois, 1992). Furthermore, for people who use ability and the prevention of suicide – A re-analysis of secular hanging, there is little opportunity for change of mind since trends in England and Wales 1950–1975. Social Psychiatry death occurs rapidly after suspension (Gunnell, Bennewith, and Psychiatry Epidemiology, 35, 437–443. Hawton, Simkin, & Kapur, 2005). Also, ligature points such Janghorbani, M., & Sharifirad, G. (2005). Completed and at- as rafters, beams, banister, hooks, trees, and hanging means tempted suicide in Ilam, Iran (1995–2002): Incidence and as- such as rope, belts, electric wire are in use everywhere and sociated factors. Archive of Iranian Medicine, 8, 119–126. are thus easily available (Gunnell et al., 2005). Kelly, S., & Bunting, J. (1998). Trends in suicide in England and All these characteristics of hanging make it extremely dif- Wales,1982–96. Population Trends, 92, 29–41. ficult to prevent suicide deaths by this method (Cantor & Kreitman N. (1976). The coal gas story. British Journal of Pre- ventive and Social Medicine, 30, 86–93. Baume, 1998). Although it might be possible to limit hangings Moradi, S., & Khademi, A. (2002). A survey on suicides within within controlled environments such as police custody facili- Iran. Legal Medicine Journal, 27, 16–21. (in Farsi) ties, prisons, and psychiatric inpatient facilities, still nearly Rezaeian, M. (2007). The age and sex suicide pattern in the East- 10% of suicides by hanging occur within just these environ- ern Mediterranean region based on the global burden of dis- ments (Gunnell et al., 2005). Since we have no information in ease estimates for 2000. East Mediterranean Health Journal, our database about the place in which the suicide happened, 13, 10–17. we are not able to determine what proportion of suicides by Simounet, C., & Bourgeois, M. (1992). Suicides and attempted sui- hangings within Tehran happened in such controlled environ- cides by hanging. Annales médico-psychologiques, 150, 481–85. ments and therefore could have been prevented. World Health Organization. (1978). The ninth revision of the in- Based on these points, the authors suggest that, to pre- ternational classification of disease and related health prob- vent suicide by hanging in Tehran and elsewhere, the au- lems (ICD-9). Geneva: Author. thorities should focus on the causal factors of suicide (pri- Yip, P.S.F. (2001). An epidemiological profile of suicide in Bei- mary prevention) rather than on the acceptability and/or the jing, China. Suicide and Life-Threatening Behavior, 31, 62–70. availability of this method (secondary or even tertiary pre- Zacharakis, C.A. Madianos, M.G. Papadimitriou, G.N., & Ste- ventions). To prevent suicide at the primary level, the au- fanis, C.N. (1998). Suicide in Greece 1980–1995: Patterns and social factors. Social Psychiatry and Psychiatry Epidemiology, thorities should tackle poverty, reduce unemployment and 33, 471–476. job insecurity, develop programs for mental health care, and provide social supports for the high-risk groups (Rezaeian, 2007). About the authors

Acknowledgments Mohsen Rezaeian got his PhD in epidemiology from the University of Manchester and now is working as an Associate Professor in the The authors would like to thanks Ms Saadatmand of the Social Medicine Department of Rasanjan Medical School, Iran. Beheshet Zahra Organization for providing us with the information. Maryam Mohammadi, Malihe Akbari, and Maryam Maleki respectively got their Bachelor degrees in Public Health from Sha- heed Beheshti University of Medical Sciences, Iran. References Mohsen Rezaeian Adityanjee, D.R. (1986). Suicide attempts and suicides in India: Cross-cultural aspects. International Journal of Social Psychi- Social Medicine Department atry, 32, 64–73. Rafsanjan Medical School Cantor, C.H., & Baume, P.J.M. (1998). Access to methods of sui- Rafsanjan, Iran cide: What impact? Australia and New Zealand Journal of Tel. +98 391 523-4003 Psychiatry, 32, 8–14. E-mail [email protected]

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