Public Health Factors Predicting Suicide among Russians in Estonia in Comparison with Estonians: Case-Control Study Kairi Kõlves1,2, Merike Sisask1, Liivia Anion1, Algi Samm1,2, Airi Värnik1,2, 3 1Estonian-Swedish Mental Aim To explore differences between suicide victims among Russian Health and Suicidology Institute, immigrants in Estonia and native Estonians, according to socio-demo- Estonian Centre of Behavioral and graphic background, substance use pattern, and recent life events to Health Sciences, Tallinn, Estonia 2Tartu University, Faculty of Social find out immigration-specific factors predicting suicide. Sciences, Methods The psychological autopsy study included 427 people who Tartu, Estonia committed suicide in 1999 and 427 randomly selected controls 3Swedish National and Stockholm matched by region, gender, age, and nationality. County Centre for Suicide Research and Prevention of Results The only variable that differed significantly between Russian Mental Ill-Health, Institute and Estonian suicide cases was substance use pattern. Logistic regression for Psychosocial Medicine; Department of Public Health models showed that factors associated with suicide for both nationali- Sciences, Karolinska Institute, ties were substance dependence and abuse (Russians: odds ratio [OR], Stockholm, Sweden 12.9; 95% confidence interval [95% CI], 4.2-39.2; Estonians: OR, 8.1; 95% CI, 3.9-16.4), economical inactivity (Russians: OR 5.5; 95% CI, 1.3-22.9; Estonians: OR, 3.1; 95% CI, 1.3-7.1), and recent family dis- cord (Russians: OR, 3.2; 95% CI, 1.1-9.9; Estonians: OR, 4.5; 95%, CI, > Correspondence to: 2.1-9.8). The variables that remained significant in the final model were Kairi Kõlves having no partner (Estonians: OR, 3.0; 95% CI, 1.6-5.5), being unem- Estonian-Swedish Mental Health and ployed (Estonians: OR, 5.5; 95% CI, 2.0-15.4), and being an abstainer Suicidology Institute, Estonian Centre of Behavioural and Health Sciences (Estonians: OR, 6.7; 95% CI, 2.5-17.6) for Estonians, and somatic ill- Őie 39 ness (Russians: OR, 4.1; 95% CI, 1.4-11.7), separation (Russians: OR, Tallinn 11615, Estonia 32.3; 95% CI, 2.9-364.1), and death of a close person (Russians: OR, [email protected] 0.2; 95% CI, 0.04-0.7) for Russians. Conclusion Although the predicting factors of suicide were similar among the Estonian Russians and Estonians, there were still some dif- > Received: June 6, 2006 ferences in the nature of recent life events. Higher suicide rate among > Accepted: September 26, 2006 Estonian Russians in 1999 could be at least partly attributable to their higher substance consumption. > Croat Med J. 2006;47:869-77 www.cmj.hr 869 Croat Med J 2006;47:869-877 Several studies compared suicide rates of immi- 53% with their fluency in the host language. grant population, native population in the host However, in this study no controls were used. country, and population in the country of ori- Since there were differences in suicide rates gin. Previous research has shown variance in the between Russian immigrants in Estonia and na- suicide rates of immigrant groups with different tive Estonians, the purpose of the present study ethnic background, as well as different suicide was to explore possible differences between sui- rates in their home countries (1-8). Differences cide victims of these two main ethnic groups in between suicide rates of immigrant groups and Estonia according to socio-demographic back- native population are not quite clear, but most of ground, substance use pattern, and recent life the immigrant groups have higher suicide rates events to find out immigration-specific factors than the population in their countries of origin. predicting suicide on the individual level. A number of studies found that migrants who had high suicide rates came from countries with Material and methods high rates and vice versa (1,2,4,9,10). Data collection Reports from England and Wales (3), Cana- da (5), and Sweden (6,11) showed very high sui- Suicides. A preliminary list of completed suicides cide rates among Russian immigrants compared was obtained from the police and the bureau of with the rates of the population both in their forensic medicine and it was verified by the data country of origin and in the host country. Jo- of the Estonian Statistical Office. In 1999, a total hansson et al (11) found that suicide rate of Rus- of 469 suicide cases (code E950-E959 by ICD- sian male immigrants in Sweden was 201.9 per 9) were registered. A psychological autopsy study 100000 in comparison with 41.4 in Russian men (15) was carried out in 427 suicide cases (91% of in Russia and 44.5 in Swedish men in 1986-1989. total, representative in terms of region, gender, and age) by means of face-to-face interviews with Värnik et al (12) compared suicide rates of relatives and intimates of suicide victims, con- Russians in Estonia, Estonians in Estonia, and ducted by psychiatrists trained for the study. The inhabitants of Russia before (1983-1990) and af- questionnaire used for the semi-structured in- ter (1991-1998) Estonia gained independence. terviews was created in Finland (16). Additional Suicide rates of Russian immigrants were lowest information was compiled from the medical re- in the period before Estonian independence and cords in hospital archives. The approval for the highest in the period after reestablishing inde- study was obtained from the Karolinska Institute pendence. In 1998, Russian and Estonian suicide Research Ethics Committee North. rates were similar (12), but in the 1991-2001pe- Control group. Persons (n = 427) with the riod, mean suicide rates in Estonian Russians same parameters (gender, age, nationality) as sui- were higher than in Estonians (38.2 and 31.9 per cide victims were randomly selected from the lists 100000, respectively) (13). of general practitioners (GPs) for the years 2002- There is a lack of studies on specific suicide 2003. GP lists are compiled from population reg- risk factors for immigrants on the individual lev- isters and contain the names of all local residents, el. As far as we know, the only study available regardless of whether they had consulted a doc- was a psychological autopsy study on suicides of tor for their health problems. Controls were Ethiopian immigrants to Israel (14). They found paired with suicide cases by region, gender, age that 67% of suicide victims were dissatisfied with (±2 years), and nationality. Interviews with the their employment, 50% with their economic sta- control group were carried out by GPs trained tus, 44% with their marital relationships, and for the study, using semi-structured question- 870 Kőlves et al: Factors Predicting Suicide among Russian Immigrants naires similar to those used for the psychological tion and Russians constituted the largest ethnic autopsy. The controls’ response rate was 96%. minority group (8.2%) (22). In the post-war period, due to the geopoliti- Description of subjects cal change related to the incorporation of Esto- A total of 57.1% of people who committed sui- nia into the Soviet Union, the Russian popula- cide were Estonians and 42.9% non-Estonians. tion grew to approximately 30% in 1989 (22). Ninety-four percent of non-Estonian suicide In 1993-1996 period, a remigration of Russians, victims were of Slavic origin – Russian (88%), mainly military forces, took place. According to Ukrainian (7%), Belarusian (5%), and Polish the 2000 census the Estonian population con- (2%) – with homogeneous cultural and linguis- sisted of 67.9% Estonians, 25.6% Russians, and tic backgrounds, and are subsumed under the 6.5% other nationalities (23). term “Russians” in the present study. Other 8 (4%) non-Estonian suicide victims were exclud- Statistical analysis ed from the study. The statistical analyses were performed with the Statistical Package for the Social Sciences, version Instrument 11.5 (SPSS Inc., Chicago, IL, USA) and Stats- The instrument applied was based on the ques- Direct version 2.3.7 (StatsDirect Ltd, Altrin- tionnaire elaborated for the National Suicide cham, UK). To estimate the association between Prevention Project in Finland (16). The semi- matched pairs in terms of potential risk factors, structured interview included everyday life, life the odds ratio (OR) was calculated using condi- event, and substance use questionnaires. Life tional logistic regression with 95% confidence event questionnaire was based on the Recent Life intervals (95% CI). The binomial test was used Change Questionnaire formulated by Rahe (17) when a specific factor was not observed in a com- with modifications from the list of Paykel et al parison subject, since the OR could not be com- (18). Life event categories analyzed in the study puted in such cases. To estimate the differences are described in more detail elsewhere (19). between suicides in nationality groups, gender, and age adjusted OR and 95% CI were calculat- Alcohol and drug diagnoses ed. To estimate the independent contribution One author-interviewer (AV) coded alcohol and of different risk factors predicting suicide among drug use in all suicide and control cases, by blind Estonians and Russians, conditional logistic re- method, using the psychological autopsy data gression models were performed. Backward selec- and medical documentation, according to hier- tion of variables was carried out to identify those archical DSM-IV principles (20,21). Pattern of variables to be retained in the final model. The substance use was classified as follows: 1) sub- level of statistical significance was set at α= 0.05. stance dependence or abuse, 2) abstinence (in- cluding former use), 3) indistinct, and 4) moder- Drop-out ate use of alcohol. Alcohol users not assigned to In the substance use analysis, 12 pairs in which categories 1-3 were considered “moderate.” sufficient data on either the suicide cases or the controls were not available to make research di- Background of Russian immigrants in Estonia agnoses were classified as indistinct and exclud- The population of Estonia was ethnically rather ed.