Collection: European Project ANAMORT Monographs June 2008 Suicide-related deaths in an enlarged European Union Objective using the last available data for a given year. The objective of this monograph is to provide Crude death rate (CDR) was obtained by producers and users of death statistics with a dividing the number of death by the last practical tool to help study deaths related to estimate of the population available in Eurostat suicides. (for a given age group if age specific crude death rate was computed). Age-standardised Methods death rate (SDR) was computed by direct Mortality data produced by health authorities of standardisation, using the 1976 European 33 European countries1 and compiled yearly population . The potential years of life lost by Eurostat2 were used. Depending on their before 75 years-old (PYLL75) due to a given availability, data were used to describe time cause were calculated for each age group by trends, geographical distributions and multiplying the number of deaths related to this demographical risks. cause by the difference between age 75 and By reviewing the literature, the international the mean age at death in each age group. forum for mortality specialists3, the revision Potential years of life lost were the sum of the and update process of the International products obtained for each age group. Classification of Diseases (ICD) and the Proportions of PYLL75 were calculated by answers of a questionnaire filled in by death dividing the PYLL75 due to a given cause by 4 statistics producers of 36 European countries the total amount of PYLL75 due to all causes 5 in the framework of the ANAMORT project , it of death. Indicators were produced at country 6 7 has been possible to: level, for all countries of EU15 or EU25 . For - describe the limits of the observed other groups of countries, estimation of a given differences indicator was calculated as an average of this - elaborate recommendations for a better use indicator at country level weighed by the of available data proportion of its population among the group. - elaborate recommendations for a better production of future data Situation regarding deaths Definition of deaths related to suicides Death from suicide was considered as any from suicide in Europe death reported to Eurostat with an underlying The number of deaths from suicide in EU25 cause of death coded X60 to X84 (table 1) in was 56,030 in 2005, which represented 24.4% the 10th revision of ICD (ICD-10). of deaths due to external causes. SDR for suicide was 10.8 for 100,000 inhabitants in 2005, among the 25 countries of the European Definition of indicators used Union. Variations between 2.9 and 37.0 The number of deaths for each group of /100,000/year according to the countries were underlying causes of death (UCoD) was the observed in Europe (Figure 1). one transmitted by the countries’ national authorities to Eurostat for a given year. The aggregation of number of deaths for the European Union (EU) was made by Eurostat, 1 Included the 25 Member States of the European Union before 2007 , Albania, Bulgaria, Croatia, Iceland, Macedonia, Norway, Romania 6 and Switzerland EU15 comprised the following 15 countries: Austria, Belgium, 2 Denmark, Finland, France, Germany, Greece, Ireland, Italy, http://epp.eurostat.ec.europa.eu 3 Luxembourg, the Netherlands, Portugal, Spain, Sweden, and the http://www.nordclass.uu.se/index_e.htm United Kingdom. 4 33 above mentioned countries, Bosnia Herzegovina, Serbia and 7 EU25 comprised EU15 and the following 10 countries: Cyprus, Turkey Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, 5 http://www.invs.sante.fr/surveillance/anamort Slovak Republic, and Slovenia. * Owing to missing data for 2005, the map Figure 1 Age-standardised mortality rate by suicide in Europe in 2005* In 2005, southern European countries had the lowest SDR by suicide as observed in Cyprus, Greece, Malta, Albania, Italy, Macedonia, Spain, and Portugal. The British islands (United Kingdom and Ireland) and Iceland also had low SDR. Regardless of age, the CDRs by suicide for men were higher than for women (Figure 2). The risk of death by suicide was 3.3 times higher among men Belgium, 2001 for Denmark and 2003 for Italy. (average for EU25 in 2005). In 2005 among EU25 countries, victims were observed among the elderly (65 years-old and more) in 33% of the cases. Compared to 15-24 years-old, the risk of death of the elderly (65 years-old and more) was three times higher. Among men a regular increase of risk was observe after the age of 15. Among women this association with age was also observed between 15 and 49 years old (figure 2). Figure 2 Crude rates of mortality by suicide by gender and age group in the European Union (25 countries) in 2005 – logarithmic scale. included data for 2004 for Albania, 1998 for Death rate / 100 000 population / year 100 10 1 0,1 The SDR has decreased by 8% between 2000 and 2005 (from 11.800 - to04 9.6/ European Union of 25 countries. (Figure 3). This trend was also observed over 0a5 longer - 09 period in the European Union of 15 countries (minus 19% between 1994 and 2005). In most of the countries,10 - 14 SDR decreases had been observed over time except for Poland, Iceland and Portugal. No visible 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 impact of ICD-10 implementation was found on trends, apart from Portugal in 2002. Actually, the 40 - 44 increase for the risk of death by suicide in Portugal started in 2001 and was completely compensated by 45 - 49 the decrease of the SDR for undetermined intent and associated with an effort of complementary 50 - 54 investigations between 2001 and 2005. Due to the small number of cases declared, the trend was 55 - 59 difficult to establish for Poland and for Iceland. The 10 new Member States, mostly in Eastern Europe, 100,000/year) in6 0 the- 64 explained the increase in death rates by suicide in the European Union (EU25 versus EU15) was due 65 - 69 to higher incidence rates in these countries (Figure Female Male 3). Age groups7 0 - 74 Figure 3 Trends in age-standardised deaths by suicide in the 75 - 79 European Union (25 countries). 80 - 84 14 12 10 8 deaths/1006 000/year 4 2 In countries where data were available (23 countries) in 2005, hanging0 and suffocation were the leading causes, followed decreasingly by poisoning, firearm, fall, drowning and cut 1994and 1995pierce. 1996 Variations 1997 1998 1999 2000 2001 2002 2003 2004 2005 European Union (15 countries) in the method of suicides were observed in the European Union (25 countries) different countries. In EU25, deaths from suicide were responsible for 30% of the PYLL by external causes of death. The highest impact was among people between 20 and 54 years of age (Figure 4). Figure 4 Distribution of potential years of life lost by suicide in the European Union (25 countries) by age group years 25 may prevent a given cause of death whatever the 20 intent is. When studying suicide trends and identifying an 15 increasing number of suicides (according to time or % location), it should be useful to investigate whether 10 this observation is linked to an increasing rate of 5 autopsies together with a decreasing proportion of deaths with undetermined intent. 0 00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 Age groups (years) Recommendations to improve Interpretation and limits of comparability of future data observed differences in deaths by collected (for data producers) suicide in Europe To better identify and code suicides, intent should be Under estimation of suicides in death statistics was more clearly assessed during certification. considered as common in most of the European Therefore, it should be useful to add a box in the countries (20 out of 36), mainly due to the death certificate to identify systematically the intent certification process. Definition of intent (sometimes in deaths taking into account the difference between called “manner of death”) is not standardised in intent needed for judicial purposes (as part of a trial) Europe. This may lead to variable underestimation and possible intent which is a purpose of the death of the magnitude of deaths from suicide. This may certificate. be a critical issue in countries where the death Possible values for intent could be: certificates are used for individual purposes and - "no" for disease or accident transmitted to insurance companies, administrations - "suspected or possible homicide" or the public without any ethical approval; in this - "suspected or possible suicide" case a certifier will need much more proof of intent - "undetermined intent" to write the information on the death certificate. In - "other" for operation of war, legal intervention, addition, for some other countries, certifiers do not etc. usually put suicide as the underlying cause of death For the same purposes, common criteria for the as they represent a strong prejudice for cultural and determination of suicide and suspected suicide religious reasons. should be defined. For specific causes of death, some countries may Physicians should be trained to better specify in the apply ICD-10 coding rules differently: hanging, death certificate all information useful for codification where the intention is not determined, may be (circumstances, intent, place and date of external systematically coded as a suicide in many countries factor causing death, etc.). (coded as hanging with undetermined intent in As underlined by an ICD-10 update, suicide (X60- others); drowning, where intention is not determined, X84) should not be accepted as due to any other may be systematically coded as accidental in some condition when selecting the underlying cause of countries (coded as drowning with undetermined death.