Journal of Affective Disorders 174 (2015) 131–136
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Rate of suicide and suicide attempts and their relationship to unemployment in Thessaloniki Greece (2000–2012) Konstantinos N. Fountoulakis a, Christos Savopoulos b,n, Martha Apostolopoulou c, Roxani Dampali d, Eleni Zaggelidou e, Eleni Karlafti f, Ilias Fountoukidis g, Pavlos Kountis h, Vasilis Limenopoulos i, Eustratios Plomaritis j, Pavlos Theodorakis k, Apostolos I Hatzitolios l a
3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Greece 1st Propedeutic Department of Internal Medicine, School of Medicine, Aristotle University, AHEPA Hospital, Thessaloniki, Greece c Internal Medicine Department, Agios Pavlos Hospital, Thessaloniki, Greece d Achladochori Prefectural Outpatient Clinic, Serres County, Greece e Forensic Service of Thessaloniki, Ministry of Justice, Thessaloniki, Greece f 1st Propedeutic Department of Internal Medicine, AHEPA Hospital, Thessaloniki, Greece g Internal Medicine Department, Agios Pavlos Hospital, Thessaloniki, Greece h Internal Medicine Department, “G. Gennimatas” Hospital, Thessaloniki, Greece i Department of Internal Medicine, “G. Gennimatas” Hospital, Thessaloniki, Greece j Department of Internal Medicine, Agios Pavlos Hospital, Thessaloniki, Greece k WHO National Counterpart for Mental Health, Greece l 1st Propedeutic Department of Internal Medicine, School of Medicine, Aristotle University, AHEPA Hospital, Thessaloniki, Greece b
art ic l e i nf o Article history: Received 21 June 2014 Received in revised form 20 November 2014 Accepted 22 November 2014 Available online 29 November 2014 Keywords: Suicide attempts Austerity Greece
Introduction: Recently there was a debate concerning the relationship between the economic crisis and an increase in attempted and completed suicides in Europe and especially in Greece. The aim of the current study was to calculate the rates of attempted and completed suicide per year in the county of Thessaloniki, Macedonia, northern Greece, for the years 2000–12, and to investigate their relationship with unemployment. Material and methods: The archive of the Emergency Outpatient Units of three hospitals was investigated and the results were projected to the county population. Data from the Hellenic statistics authority concerning regional general population and suicides and unemployment were used. Results: The rate of attempted suicides was 16.69–40.34 per 105 inhabitants for males and 41.43–110.82 for females. Medication was the preferred method for 95.93%. The completed suicide rates varied from 3.62 to 5.47 for males and from 0.19 to 1.95 per 105 inhabitants for females. The male attempt rate correlated negatively with regional male unemployment ( 0.63). For females the respected value was similar ( 0.72). Concerning competed suicide rates, the respected values were 0.34 and 0.65. The attempt was repeated by 15.34%; almost half-repeated within the same year and 75% within two years. The female to male ratio varied significantly across years with 2:1 (more females) being the probable value for attempts and 1:3.6 (more males) for completed suicides. Conclusion: This is the first study from Greece reporting rates on the basis of hospital archives. Attempt and suicide rates are low in Greece. Attempts are negatively and suicides are positively correlated with unemployment. & 2014 Elsevier B.V. All rights reserved.
1. Introduction
n
Corresponding author. E-mail addresses: [email protected] (K.N. Fountoulakis), [email protected] (C. Savopoulos), [email protected] (M. Apostolopoulou), [email protected] (R. Dampali), [email protected] (E. Karlafti), [email protected] (I. Fountoukidis), [email protected] (P. Kountis), [email protected] (V. Limenopoulos), [email protected] (P. Theodorakis), [email protected] (A. Hatzitolios). http://dx.doi.org/10.1016/j.jad.2014.11.047 0165-0327/& 2014 Elsevier B.V. All rights reserved.
Since 2008, Greece has entered a long period of economic crisis. This had serious adverse effects on various aspects of daily life and probably on the mental health of its citizens. It is very important that the Greek Ministry of Health reported that the annual suicide rate had increased by 40%, although at the time of this announcement no relevant data were available (Hellenic Statistical Authority, 2011; Kentikelenis et al., 2011). Following this, a telephone survey reported that there was a 36% increase in the number who reported having attempted suicide in the month
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Fig. 1. The pyramid of rates related with suicidality. ‘N’ stands for the proportion of persons in the different categories. E.g. for every 20 attempts a single competed suicide exists and this also corresponds to 1600 persons who currently are thinking that it is not worth living.
before the survey took place. This increase was from 1.1% in 2009 to 1.5% in 2011. Also high economic distress was more prevalent and it was correlated with suicidal ideation (Economou et al., 2011). In accord with the above another paper reported a 17% increase in suicidal rates during 2008–9 in Greece (Stuckler et al., 2011). A different picture was reported by the Greek Statistics Authority (ELSTAT) whose data did not suggest any increase in suicides until 2010 (Fountoulakis et al., 2012; Hellenic Statistical Authority, 2011). According to the ELSTAT data the first increase in suicidal rates appeared during 2011 (Fountoulakis et al., 2013a, 2013b). Attempts and reported attempts or suicidal ideation are quite different from completed suicide. Rates are also completely different. A recent paper from our group reported that in Greece, cross-sectionally and depending on the frequency, approximately 8% were thinking that it is not worth living, 6% had a past history of self-injury, 2% had a history of suicide attempts and 1.5% had current suicidal ideation (Fig. 1) (Fountoulakis et al., 2012). These results were collected before 2008, that is before the beginning of the current crisis and are in accord with the literature (Platt et al., 1992; Schmidtke et al., 1996). It is interesting to note an important discrepancy in the literature. Although it has been reported that 9.7% of adolescents have attempted and 29.9% had thought about suicide at some point (Platt et al., 1992; Schmidtke et al., 1996) the respected lifetime data collected during the adult life (which of course include attempts during adolescence) are somewhat lower, suggesting the presence of under-reporting. Several risk factors for the manifestation of any kind of suicidal behavior have been identified. These risk factors are classified as primary (such as the presence of psychiatric and medical conditions, severe somatic illness, previous suicide attempts), secondary (adverse life situations and psychosocial risk factors) and tertiary (demographic factors such as male gender and old age) (Henriksson et al., 1993; Rihmer et al., 2002). The aim of the current study was to calculate the rate of attempted suicide per year in the county of Thessaloniki, Greece, for the years 2000–12 on the basis of the registrations in the emergency outpatient units, and to investigate the relationship between attempts, suicides and unemployment in the same region.
2. Material and methods The archive of the 1st Propedeutic Department of Internal Medicine Emergency Outpatient Unit, of University Hospital AHEPA,
Thessaloniki Greece was searched for the period from January 1st, 2000 through December 31st, 2012, to identify cases of suicidal attempts. Also the archives of the respected outpatient clinics of the hospitals ‘Agios Pavlos’ and ‘G. Genimatas’ were searched for those specific time periods they were on duty jointly with AHEPA. The archives of one of the surgical departments were also searched but eventually not included because of a very low number of cases (o10 in total). The cases of suicidal attempts are registered by the medical staff on the basis of reports by the patient himself or the family but also by taking into consideration all the relevant clinical and laboratory features of the specific case. The analysis included descriptive statistics of the raw data (absolute numbers). The next step was to calculate the rates on the basis of the days of duty this group of hospitals undertook during the period studied. The method is described in details in the webappendix. ANOVA was used to test differences between populations, Correlations between regional unemployment rates and attempted and completed suicide rates were calculated. In detail the sources of data and the method are described in Part A of the webappendix. The analysis, along with the results are described in a step-by-step way in parts B, C and D of the webappendix.
3. Results The search of the archives identified 940 registrations of suicidal attempts during the years 2000–2012 940. These registrations corresponded to 919 individual persons (females: N ¼ 651, 70.84%; males: N ¼ 268, 29.16%). The mean age was 34.99 716.91 (range 15–90) years for females and 39.69 718.35 (range 15–95) years for males. All of them survived the attempt. The numbers of attempts concerning each sex in each year and the respected female-to-male ratio (with the use of absolute raw numbers) are shown in webappendix- Table I. The vast majority (94.26%) attempted by using medication pills (webappendix Table II). Males preferred more violent ways (e.g. 6.88% males vs. 3.31% females attempted with toxic substances, 0.72% vs. 0.15% fell into the sea) but the numbers were too small for statistical testing. The calculated rates of suicidal attempts varied from 29.57 (for 2011) to 70.77 per 105 inhabitants (for 2006). The detailed rates by sex and year are shown in Table 1.
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Table 1 Rates of regional unemployment, suicide rates and completed suicides in the two sexes Unv¼ unavailable. year Males Regional unemployment 2000 8.7 2001 7.5 2002 8.4 2003 6.7 2004 7 2005 7.3 2006 6.5 2007 6.1 2008 5.4 2009 8.9 2010 10.4 2011 16.8 2012 24.7 a
Females Estimate rate attempts per year
Rate of suicides per year
Regional unemployment
23.37 38.96 34.23 35.65 26.40
3.67 3.62 3.80 5.09 5.06 5.47 3.69 4.52 3.85 4.67 4.23 5.07 4.22a
18.1 16.7 17.1 14.5 17.8 18.1 14.1 12.9 14 14.7 16.1 24.3 30.1
27.33 37.26 38.71 40.34 34.23 16.69 31.68
Estimate rate attempts per year 65.50 71.87 84.45 59.76 49.48 110.82 85.96 80.19 85.24 76.86 41.43 59.33
Rate of suicides per year 1.47 1.04 1.44 1.02 1.62 1.21 0.40 0.99 1.18 1.17 0.19 1.95 1.36a
Calculated on the same general population as previous year.
The distribution of attempts per month of year showed the presence of clear peaks during May and August, that is at the border of summer, and troughs in February and December that is at the border of winter Twenty one persons (2.28%) attempted twice (8 males, 38.10% and 13 females, 61.90%), but this is not the actual number since some second attempts could had been registered in the days of duty of another hospital. The projection suggested that a total of 141 patients out of 919 of our sample (15.34%) had attempted for a second time (webappendix Table X). The current study did not investigate whether any subjects died as a consequence of suicide after their first attempt. ANOVA with number of attempts and sex as grouping variables revealed no main effect for either variable alone or for their interaction concerning age (p4 0.05). Proportionally more males than females attempted for a second time, but the difference was not significant (χ2 ¼ 0.83, df ¼1, p ¼0.362) The time to second attempt did not differ between sexes (df ¼1, F¼ 0.656, p ¼0.428). Almost half (47.62%) committed the second attempt within the same year and an additional 23.81% within the next year. Each next year accounted for 4.76% of cases. Thus, almost half of those reattempted have done so within the same year and 75% within two years. The completed suicide rates for the years 2000–2012 are shown in Table 1. The male to female ratio varied significantly across years with an average of 5.6:1. If the years 2006 and 2010 are not taken into account (because they constitute outliers with extremely low female numbers) this ratio falls to 3.6:1 (webappendix Table XI). The male attempt rate correlated negatively with regional male unemployment ( 0.63). For females the respective value similar ( 0.72). Concerning competed suicide rates, the respective values were 0.34 and 0.65. Male attempts showed a weak negative correlation with male ( 0.21) and female suicide rates ( 0.45), while female attempts showed a strong negative correlation (4 0.60) with both male and female suicide rates. The complete matrix of correlations is shown in webappendix Table XIII. A more detailed presentation of results can be found in the webappendix.
4. Discussion The current study reports that the rates of attempted suicides in Thessaloniki, Greece for the years 2000–2012 were between 16.69 and 40.34 per 105 inhabitants for males and from 41.43 to
110.82 for females. Concerning the method, 95.93% attempted with medications. The rates were higher for the years 2006–9, but no clear tendency in relationship to time was present. The suicide rates varied from 3.62 to 5.47 for males and from 0.19 to 1.95 per 105 inhabitants for females and they were higher for the period 2003–5 and for the year 2011. Peculiarly, there was a strong negative relationship of attempts with unemployment, which explains the 2006–9 peak. On the contrary, suicide rates were positively correlated with unemployment. Two peaks were identified for attempts, and they were in May and August that is at the border of summer. There were also two troughs present, in February and December that is at the border of winter. It has been estimated that 15.34% of persons who attempted once, repeated the attempt and almost half of them had done so within the same year. Within two years 75% of those who repeated the attempt had done so. The female to male ratio varied significantly across years with 2:1 (more females) being the probable value for attempts and 1:3.6 (more males) for completed suicides. There is a bulk of data from several countries from around the world which suggest that the suicide attempt rates vary widely. One WHO multinational study reported an average rate of 300 attempts per 105 residents for the years 2001–2007 with no difference between developing and developed countries (Borges et al., 2010). Another WHO study reported that in Europe the highest average male age-standardized rate of suicide attempts was found for Helsinki, Finland (314/105), and the lowest rate was found for Guipuzcoa, Spain (45/105) (Schmidtke et al., 1996). However, often studies report significantly different results even when they come from the same country and concern the same time period. For example for Turkey, rates for males vary from 31.9 to 46.89 and for females from 60.42 to 112.89 per 105 inhabitants (Devrimci-Ozguven and Sayil, 2003; Sayil and Devrimci-Ozguven, 2002; Turhan et al., 2011). This is especially striking in the US where the rates vary by state. With an average of 500 per 105 inhabitants across the country, the variability is great with rates ranging from 100 in Delaware and Georgia to 1500 per 105 inhabitants in Rhode Island (Baca-Garcia et al., 2003; Birkhead et al., 1993; Borges et al., 2006; Crosby et al., 1999; Crosby et al., 2011; Kessler et al., 2005; Kuo et al., 2001; Roesler et al., 2009). Race might also play an important role with blacks attempting 1.5–2 more in comparison to Caucasians and Hispanics (Birkhead et al., 1993; Prosser et al., 2007). The rates from the other anglo-saxon countries vary with Australia and New Zealand averaging 400 attempts per 105 inhabitants (Beautrais et al., 2006; Fairweather-Schmidt and Anstey,
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2011; Johnston et al., 2009; Pirkis et al., 2000) while the UK had somewhat lower rates (males 211–280, females 296–497, for 1976– 1990; no change for men, decline over the years for women) (Hawton and Fagg, 1992). Canada had the lowest rate for the years 1998–2000 (76.1 for females and 60.3 per 105 inhabitants for males) (Alaghehbandan et al., 2005) For the Netherlands, the reported rates vary widely from below 50 up to 300 per 105 inhabitants (Arensman et al., 1995; Marquet et al., 2005; ten Have et al., 2009). For Denmark the rate is probably around 500 (Kjoller and Helweg-Larsen, 2000), while for Belgium the data are more consistent with rates around 60–70 for males and 70–140 per 105 inhabitants for females (Boffin et al., 2011; Bossuyt and Van Casteren, 2007; Van Casteren et al., 1993). These rates are generally similar to the rates reported concerning Germany (Bogdanovica et al., 2010) and Sweden (Bogdanovica et al., 2010). Ireland and Latvia reported rates slightly above 150,300 per 105 inhabitants (Arensman et al., 1995; Corcoran et al., 2004; Marquet et al., 2005; Rancans et al., 2001; ten Have et al., 2009). Unfortunately concerning Italy the data vary so much that they should not be considered to be reliable (Majori et al., 2004; Poma et al., 2007). There is a lack of data concerning the rest of the world. There are some reports which suggest that the rate for China was 160 per 105 inhabitants for the years 1995–1999 (2004), for Israel the rate was 16.7 105 inhabitants (Arabs, 24.4 and Jews, 11.0) for the years 1996–7 (Ashkar et al., 2006) and for Brazil the rate was probably around 400 per 105 inhabitants (Botega et al., 2005). Taking into consideration the international rates mentioned above, it is clear that the rates reported in the current study are one of the lowest rates for suicidal attempts in the world. This is in accord with the data coming from other Mediterranean countries. It is interesting to note that the use of medication in our study was overwhelmingly high, but it is unlikely that this constitutes a bias or limitation. Also an issue open for debate is the very low number of surgical cases. There are previous reports from Greece on the epidemiology of attempted suicide using different methods and indices. In the first one, an epidemiological interviewer-based method was used and reported the prevalence of attempted suicide for the year prior to interview. These rates were 0.27% for males and 1.10% for females for the year 1978 and 1.5% and 3.4% respectively for the year 1984 (Madianos et al., 1993). Although similar figures are reported in the literature concerning other countries, these data cannot be compared to those of the current study. If one extrapolates the 1978 figures into rates per 105 inhabitants, the figures are 10-fold higher for males and 15-fold or more for females in comparison to our findings. The figures from 1984 are even higher. This is a problem of different methodologies and it is widespread in the literature. More recent studies calculated the rates for the period 2009–2011 by using a telephone survey method. They reported an increase in reported suicide attempts from 1.1% (for 2009) to 1.5% (for 2011) for the month previous to the interviewing (Economou et al., 2013, 2011). In these latter two studies the ‘previous month’ attempt rate is almost similar to the rate reported in the 1978–84 study concerning the ‘previous year’. This later observation is important because a rate of 1.1–1.5% per month implies that (after taking into consideration repeating of attempts also) approximately 10–18% of the population will attempt within a year, raising the absolute numbers to millions. Probably the subjects could not focus their responses on the previous month or even year, and instead many of them reported their lifetime experience. They also might had reported simple self-destructive acts or even suicidal ideation as attempts. It should be noted that 1% per month of the 18þpopulation in Greece (approx. 6 million) corresponds to 2000 attempts per day and to ¾ of a million per year (12,500 per 105 inhabitants). Similarly, 1% per year corresponds to 1000 per 105 inhabitants.
In the literature, the reported rate of female to male attempts varies from 2–3:1 to even 1:1 in more recent studies (Alaghehbandan et al., 2005; Baydin et al., 2005; Bille-Brahe et al., 1997; Bogdanovica et al., 2010; De Leo et al., 2001; Fushimi et al., 2006; Hawton and Fagg, 1992; Hulten et al., 2001; Kovess-Masfety et al., 2011; Majori et al., 2004; Marquet et al., 2005; Rancans et al., 2001). It is possible that women do not attempt suicide more frequently than men, except for 13–26 year olds (Levinson et al., 2006). The current study reports that the most probable ratio for Greece is 2:1 but with significant variability between years, and the trend is a decline of the ratio. This is more or less in accord with previous studies suggested that in Greece during 1971–72 the ratio of female to male in persons who attempted was 4.6:1 and it had fell to 2.3:1 in 1994–96 (Ierodiakonou et al., 1998) An important limitation of the current study but also for the literature in general is that the majority of attempts might not reach the emergency room and they are not even seen by a health professional. It has been reported that less than 30% go to the hospital (De Leo et al., 2005) and no more than 50–60% become known to the healthcare system (Kjoller and Helweg-Larsen, 2000). Probably one third consults a medical practitioner and one fifth a psychiatrist. (Ma et al., 2009). This probably means that the real attempt rate in Greece is triple than the one reported by the current study. An important confounder in the current study is the fact that for the years 2005–9 a different system for the treatment of emergency cases was in place. It is unknown how this could have affected the data since proximity is a factor which can determine seeking help after an attempt. In terms of risk factors, there are two studies which identified current unemployment as a risk factor (OR¼2–4) but both suggested it is not a primary cause (Beautrais et al., 1998; Fergusson et al., 2007). Another one found no effect of unemployment (Lorensini and Bates, 2002). Low income seems to correlate with attempts (Kalist et al., 2007). Other risk factors include age (425 years), female sex, race, unmarried status, lower education level, lower or higher monthly income and presence of major mental and medical disorders (Ma et al., 2009; Majori et al., 2004; Mazza et al., 2011; McMillan et al., 2010; Nock and Kessler, 2006; Pirkis et al., 2000). The current study, reports a negative correlation between attempts and regional unemployment, while on the contrary the correlation is positive between completed suicides and unemployment. This was true both for males and females. Additionally, there was a strong negative correlation between female attempts and female suicides while the respective correlation was weak in males. All the above suggests that female attempts are not only higher in rate in comparison to male attempts but they might also differ in quality. This might mean that female attempts could be potentially more serious in terms of intention. Although the literature is limited, it seems that internationally, medication seems to be the dominant method of attempting (Hatzitolios et al., 2001; Jaraczewska and Czerczak, 1994) followed by pesticides. This dominance of medication is especially evident in high income countries (Kawashima et al., 2014) while data related to suicides in low and middle income countries are fairly limited (Milner and De Leo, 2010; Vijayakumar et al., 2005). On the other hand, in low income countries pesticides seem to be the dominant method (Fleischmann et al., 2005). This could well reflect a difference between countries concerning access to potentially poisonous substances. In the current study the overall dominance of medication use was remarkable and above 95%, but it is unlikely it constitutes a limitation of the study. While the current study reports that 15.34% of people who attempted once repeat the attempt with half of them doing so within the first year, the literature suggests that around 8% repeat the attempt within one year, and this is perfectly in accord with our
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results (Corcoran et al., 2004; Dieserud et al., 2010; Hulten et al., 2001). It has also been reported that to 44% repeats the attempt within 8–10 years (Christiansen and Jensen, 2007; Groholt and Ekeberg, 2009; Tejedor et al., 1999). Finally, there are reports on a seasonal pattern in the rate of suicide attempts with peaks during the spring and summer and troughs during the autumn and winter. However the data are complex and a number of confounding variables exist, including gender, social cues and diagnosis (Baydin et al., 2005; Hiltunen et al., 2012; Jessen et al., 1999; Kordic et al., 2010; Mergl et al., 2010; Preti and Miotto, 2000; Valtonen et al., 2006; Yip and Yang, 2004). Our results identified specific months, are generally in accord with a summer peak and winter low, but the findings were somewhat inconsistent across years Role of funding source None.
Conflict of interest None.
Acknowledgments None.
Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jad.2014.11.047. References Alaghehbandan, R., Gates, K.D., MacDonald, D., 2005. Suicide attempts and associated factors in Newfoundland and Labrador, 1998–2000. Can. J. Psychiatry 50, 762–768. Arensman, E., Kerkhof, A.J., Hengeveld, M.W., Mulder, J.D., 1995. Medically treated suicide attempts: a four year monitoring study of the epidemiology in The Netherlands. J. Epidemiol. Community Health 49, 285–289. Ashkar, K., Giloni, C., Grinshpoon, A., Geraisy, N., Gruner, E., Cohen, R., Paryente, O., Nassar, F., Ponizovsky, A.M., 2006. Suicidal attempts admitted to a general hospital in the Western Galilee: an inter-ethnic comparison study. Isr. J. Psychiatry Relat. Sci. 43, 137–145. Baca-Garcia, E., Diaz-Sastre, C., Ceverino, A., Saiz-Ruiz, J., Diaz, F.J., de Leon, J., 2003. Association between the menses and suicide attempts: a replication study. Psychosom. Med. 65, 237–244. Baydin, A., Yardan, T., Aygun, D., Doganay, Z., Nargis, C., Incealtin, O., 2005. Retrospective evaluation of emergency service patients with poisoning: a 3-year study. Adv. Ther. 22, 650–658. Beautrais, A.L., Joyce, P.R., Mulder, R.T., 1998. Unemployment and serious suicide attempts. Psychol. Med. 28, 209–218. Beautrais, A.L., Wells, J.E., McGee, M.A., Oakley Browne, M.A., 2006. Suicidal behaviour in Te Rau Hinengaro: the New Zealand Mental Health Survey. Aust. N. Z. J. Psychiatry 40, 896–904. Bille-Brahe, U., Kerkhof, A., De Leo, D., Schmidtke, A., Crepet, P., Lonnqvist, J., Michel, K., Salander-Renberg, E., Stiles, T.C., Wasserman, D., Aagaard, B., Egebo, H., Jensen, B., 1997. A repetition-prediction study of European parasuicide populations: a summary of the first report from part II of the WHO/EURO Multicentre Study on Parasuicide in co-operation with the EC concerted action on attempted suicide. Acta Psychiatr. Scand. 95, 81–86. Birkhead, G.S., Galvin, V.G., Meehan, P.J., O'Carroll, P.W., Mercy, J.A., 1993. The emergency department in surveillance of attempted suicide: findings and methodologic considerations. Public Health Rep. 108, 323–331. Boffin, N., Bossuyt, N., Vanthomme, K., Van Casteren, V., 2011. Declining rates of suicidal behavior among general practice patients in Belgium: results from sentinel surveillance between 1993 and 2008. Arch. Suicide Res. 15, 68–74. Bogdanovica, I., Jiang, G.X., Lohr, C., Schmidtke, A., Mittendorfer-Rutz, E., 2010. Changes in rates, methods and characteristics of suicide attempters over a 15-year period: comparison between Stockholm, Sweden, and Wurzburg, Germany. Soc. Psychiatry Psychiatr. Epidemiol. 46, 1103–1114. Borges, G., Angst, J., Nock, M.K., Ruscio, A.M., Walters, E.E., Kessler, R.C., 2006. A risk index for 12-month suicide attempts in the National Comorbidity Survey Replication (NCS-R). Psychol. Med. 36, 1747–1757. Borges, G., Nock, M.K., Haro Abad, J.M., Hwang, I., Sampson, N.A., Alonso, J., Andrade, L.H., Angermeyer, M.C., Beautrais, A., Bromet, E., Bruffaerts, R., de Girolamo, G., Florescu, S., Gureje, O., Hu, C., Karam, E.G., Kovess-Masfety, V.,
135
Lee, T., Levinson, D., Medina-Mora, M.E., Ormel, J., Posada-Villa, J., Sagar, R., Tomov, T., Uda, H., Williams, D.R., Kessler, R.C., 2010. Twelve-month prevalence of and risk factors for suicide attempts in the World Health Organization World Mental Health Surveys. J. Clin. Psychiatry 71, 1617–1628. Bossuyt, N., Van Casteren, V., 2007. Epidemiology of suicide and suicide attempts in Belgium: results from the sentinel network of general practitioners. Int. J. Public Health 52, 153–157. Botega, N.J., Barros, M.B., Oliveira, H.B., Dalgalarrondo, P., Marin-Leon, L., 2005. Suicidal behavior in the community: prevalence and factors associated with suicidal ideation. Rev. Bras. Psiquiatr. 27, 45–53. Christiansen, E., Jensen, B.F., 2007. Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: a register-based survival analysis. Aust. N. Z. J. Psychiatry 41, 257–265. Corcoran, P., Keeley, H.S., O’Sullivan, M., Perry, I.J., 2004. The incidence and repetition of attempted suicide in Ireland. Eur. J. Public Health 14, 19–23. Crosby, A.E., Cheltenham, M.P., Sacks, J.J., 1999. Incidence of suicidal ideation and behavior in the United States, 1194. Suicide Life Threat. Behav. 29, 131–140. Crosby, A.E., Han, B., Ortega, L.A., Parks, S.E., Gfroerer, J., 2011. Suicidal thoughts and behaviors among adults aged Z 18 years – United States, 2008–2009. MMWR Surveill. Summ. 60, 1–22. De Leo, D., Cerin, E., Spathonis, K., Burgis, S., 2005. Lifetime risk of suicide ideation and attempts in an Australian community: prevalence, suicidal process, and help-seeking behaviour. J. Affect. Disord. 86, 215–224. De Leo, D., Padoani, W., Scocco, P., Lie, D., Bille-Brahe, U., Arensman, E., Hjelmeland, H., Crepet, P., Haring, C., Hawton, K., Lonnqvist, J., Michel, K., Pommereau, X., Querejeta, I., Phillipe, J., Salander-Renberg, E., Schmidtke, A., Fricke, S., Weinacker, B., Tamesvary, B., Wasserman, D., Faria, S., 2001. Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour. Int. J. Geriatr. Psychiatry 16, 300–310. Devrimci-Ozguven, H., Sayil, I., 2003. Suicide attempts in Turkey: results of the WHO-EURO Multicentre Study on Suicidal Behaviour. Can. J. Psychiatry 48, 324–329. Dieserud, G., Gerhardsen, R.M., Van den Weghe, H., Corbett, K., 2010. Adolescent suicide attempts in Baerum, Norway, 1984-2006. Crisis 31, 255–264. Economou, M., Madianos, M., Peppou, L.E., Theleritis, C., Patelakis, A., Stefanis, C., 2013. Suicidal ideation and reported suicide attempts in Greece during the economic crisis. World Psychiatry 12, 53–59. Economou, M., Madianos, M., Theleritis, C., Peppou, L.E., Stefanis, C.N., 2011. Increased suicidality amid economic crisis in Greece. Lancet 378, 1459. Fairweather-Schmidt, A.K., Anstey, K.J., 2011. Prevalence of suicidal behaviours in two Australian general population surveys: methodological considerations when comparing across studies. Soc. Psychiatry Psychiatr. Epidemiol. 47, 515–522. Fergusson, D.M., Boden, J.M., Horwood, L.J., 2007. Unemployment and suicidal behavior in a New Zealand birth cohort: a fixed effects regression analysis. Crisis 28, 95–101. Fleischmann, A., Bertolote, J.M., De Leo, D., Botega, N., Phillips, M., Sisask, M., Vijayakumar, L., Malakouti, K., Schlebusch, L., De Silva, D., Nguyen, V.T., Wasserman, D., 2005. Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middleincome countries. Psychol. Med. 35, 1467–1474. Fountoulakis, K.N., Grammatikopoulos, I.A., Koupidis, S.A., Siamouli, M., Theodorakis, P.N., 2012. Health and the financial crisis in Greece. Lancet 379, 1001–1002 (author reply 1002). Fountoulakis, K.N., Koupidis, S.A., Grammatikopoulos, I.A., Theodorakis, P.N., 2013a. First reliable data suggest a possible increase in suicides in Greece. BMJ 347, f4900. Fountoulakis, K.N., Koupidis, S.A., Siamouli, M., Grammatikopoulos, I.A., Theodorakis, P.N., 2013b. Suicide, recession, and unemployment. Lancet 381, 721–722. Fushimi, M., Sugawara, J., Saito, S., 2006. Comparison of completed and attempted suicide in Akita, Japan. Psychiatry Clin. Neurosci. 60, 289–295. Groholt, B., Ekeberg, O., 2009. Prognosis after adolescent suicide attempt: mental health, psychiatric treatment, and suicide attempts in a nine-year follow-up study. Suicide Life Threat. Behav. 39, 125–136. Hatzitolios, A.I., Sion, M.L., Eleftheriadis, N.P., Toulis, E., Efstratiadis, G., Vartzopoulos, D., Ziakas, A.G., 2001. Parasuicidal poisoning treated in a Greek medical ward: epidemiology and clinical experience. Hum. Exp. Toxicol. 20, 611–617. Hawton, K., Fagg, J., 1992. Trends in deliberate self poisoning and self injury in Oxford, 1976-90. BMJ 304, 1409–1411. Hellenic Statistical Authority, 2011. December 2011. Monthly Statistical Bulletin, 56, 15. Henriksson, M.M., Aro, H.M., Marttunen, M.J., Heikkinen, M.E., Isometsa, E.T., Kuoppasalmi, K.I., Lonnqvist, J.K., 1993. Mental disorders and comorbidity in suicide. Am. J. Psychiatry 150, 935–940. Hiltunen, L., Ruuhela, R., Ostamo, A., Lonnqvist, J., Suominen, K., Partonen, T., 2012. Atmospheric pressure and suicide attempts in Helsinki, Finland. Int. J. Biometeorol.. Hulten, A., Jiang, G.X., Wasserman, D., Hawton, K., Hjelmeland, H., De Leo, D., Ostamo, A., Salander-Renberg, E., Schmidtke, A., 2001. Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors. Eur. Child Adolesc. Psychiatry 10, 161–169. Ierodiakonou, C.S., Iacovides, A., Ierodiakonou-Benou, I., 1998. Changing patterns of attempted suicide in Greece: clinicoepidemiological and psychodynamic data. Psychopathology 31, 281–292. Jaraczewska, W., Czerczak, S., 1994. The pattern of acute poisonings in Poland. Vet. Hum. Toxicol. 36, 228–233.
136
K.N. Fountoulakis et al. / Journal of Affective Disorders 174 (2015) 131–136
Jessen, G., Jensen, B.F., Arensman, E., Bille-Brahe, U., Crepet, P., De Leo, D., Hawton, K., Haring, C., Hjelmeland, H., Michel, K., Ostamo, A., Salander-Renberg, E., Schmidtke, A., Temesvary, B., Wasserman, D., 1999. Attempted suicide and major public holidays in Europe: findings from the WHO/EURO multicentre study on parasuicide. Acta Psychiatr. Scand. 99, 412–418. Johnston, A.K., Pirkis, J.E., Burgess, P.M., 2009. Suicidal thoughts and behaviours among Australian adults: findings from the 2007 National Survey of Mental Health and Wellbeing. Aust. N. Z. J. Psychiatry 43, 635–643. Kalist, D.E., Molinari, N.A., Siahaan, F., 2007. Income, employment and suicidal behavior. J. Ment. Health Policy Econ. 10, 177–187. Kawashima, Y., Yonemoto, N., Inagaki, M., Yamada, M., 2014. Prevalence of suicide attempters in emergency departments in Japan: a systematic review and metaanalysis. J. Affect. Disord. 163, 33–39. Kentikelenis, A., Karanikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D., 2011. Health effects of financial crisis: omens of a Greek tragedy. Lancet 378, 1457–1458. Kessler, R.C., Berglund, P., Borges, G., Nock, M., Wang, P.S., 2005. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 293, 2487–2495. Kjoller, M., Helweg-Larsen, M., 2000. Suicidal ideation and suicide attempts among adult Danes. Scand. J. Public Health 28, 54–61. Kordic, M., Babic, D., Petrov, B., Kordic, J., Jelavic, B., Pivic, G., 2010. The meteorological factors associated with suicide. Coll. Antropol. 34 (Suppl 1), S151–S155. Kovess-Masfety, V., Boyd, A., Haro, J.M., Bruffaerts, R., Villagut, G., Lepine, J.P., Gasquet, I., Alonso, J., 2011. High and low suicidality in Europe: a fine-grained comparison of France and Spain within the ESEMeD surveys. J. Affect. Disord. 133, 247–256. Kuo, W.H., Gallo, J.J., Tien, A.Y., 2001. Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland. Psychol. Med. 31, 1181–1191. Levinson, D., Haklai, Z., Stein, N., Gordon, E.S., 2006. Suicide attempts in israel: age by gender analysis of a national emergency departments database. Suicide Life Threat. Behav. 36, 97–102. Lorensini, S., Bates, G., 2002. Relationship difficulties and unemployment in attempted suicide in an Australian regional center. Psychol. Rep. 90, 923–929. Ma, X., Xiang, Y.T., Cai, Z.J., Li, S.R., Xiang, Y.Q., Guo, H.L., Hou, Y.Z., Li, Z.B., Li, Z.J., Tao, Y.F., Dang, W.M., Wu, X.M., Deng, J., Chan, S.S., Ungvari, G.S., Chiu, H.F., 2009. Lifetime prevalence of suicidal ideation, suicide \plans and attempts in rural and urban regions of Beijing, China. Aust. N. Z. J. Psychiatry 43, 158–166. Madianos, M.G., Madianou-Gefou, D., Stefanis, C.N., 1993. Changes in suicidal behavior among nation-wide general population samples across Greece. Eur. Arch. Psychiatry Clin. Neurosci. 243, 171–178. Majori, S., Zanin, G., Benvenuti, K., Tardivo, S., Cristofoletti, M., Baldo, V., 2004. Attempted suicides in the municipality of Padua (Italy): a retrospective survey (1996–2000). Ann. Ig. 16, 685–692. Marquet, R.L., Bartelds, A.I., Kerkhof, A.J., Schellevis, F.G., van der Zee, J., 2005. The epidemiology of suicide and attempted suicide in Dutch General Practice 1983– 2003. BMC. Fam. Pract. 6, 45. Mazza, J.J., Catalano, R.F., Abbott, R.D., Haggerty, K.P., 2011. An examination of the validity of retrospective measures of suicide attempts in youth. J. Adolesc. Health 49, 532–537. McMillan, K.A., Enns, M.W., Asmundson, G.J., Sareen, J., 2010. The association between income and distress, mental disorders, and suicidal ideation and attempts: findings from the Collaborative Psychiatric Epidemiology Surveys. J. Clin. Psychiatry 71, 1168–1175. Mergl, R., Havers, I., Althaus, D., Rihmer, Z., Schmidtke, A., Lehfeld, H., Niklewski, G., Hegerl, U., 2010. Seasonality of suicide attempts: association with gender. Eur. Arch. Psychiatry Clin. Neurosci. 260, 393–400.
Milner, A., De Leo, D., 2010. Suicide research and prevention in developing countries in Asia and the Pacific. Bull. World Health Organ. 88, 795–796. Nock, M.K., Kessler, R.C., 2006. Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. J. Abnorm. Psychol. 115, 616–623. Pirkis, J., Burgess, P., Dunt, D., 2000. Suicidal ideation and suicide attempts among Australian adults. Crisis 21, 16–25. Platt, S., Bille-Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T., Crepet, P., De Leo, D., Haring, C., Lonnqvist, J., Michel, K., et al., 1992. Parasuicide in Europe: the WHO/ EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr. Scand. 85, 97–104. Poma, S.Z., Magno, N., Belletti, S., Toniolo, E., 2007. Parasuicide in Rovigo (North of Italy) during the period 2000–2005. J. Prev. Med. Hyg. 48, 79–82. Preti, A., Miotto, P., 2000. Influence of method on seasonal distribution of attempted suicides in italy. Neuropsychobiology 41, 62–72. Prosser, J.M., Perrone, J., Pines, J.M., 2007. The epidemiology of intentional non-fatal self-harm poisoning in the United States: 2001–2004. J. Med. Toxicol. 3, 20–24. Rancans, E., Alka, I., Renberg, E.S., Jacobsson, L., 2001. Suicide attempts and serious suicide threats in the city of Riga and resulting contacts with medical services. Nord. J. Psychiatry 55, 279–286. Rihmer, Z., Belso, N., Kiss, K., 2002. Strategies for suicide prevention. Curr. Opin. Psychiatry 15, 83–87. Roesler, J., Petcoff, M., Azam, A., Westberg, S., Kinde, M., Crosby, A., 2009. Nonfatal suicide attempts and other self-inflicted harm. Beltrami County youths, 2002–2006. Minn. Med. 92, 53–55. Sayil, I., Devrimci-Ozguven, H., 2002. Suicide and suicide attempts in Ankara in 1998: results of the WHO/EURO multicentre study of suicidal behaviour. Crisis 23, 11–16. Schmidtke, A., Bille-Brahe, U., DeLeo, D., Kerkhof, A., Bjerke, T., Crepet, P., Haring, C., Hawton, K., Lonnqvist, J., Michel, K., Pommereau, X., Querejeta, I., Phillipe, I., Salander-Renberg, E., Temesvary, B., Wasserman, D., Fricke, S., Weinacker, B., Sampaio-Faria, J.G., 1996. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992 (Results of the WHO/EURO Multicentre Study on Parasuicide). Acta Psychiatr. Scand. 93, 327–338. Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., McKee, M., 2011. Effects of the 2008 recession on health: a first look at European data. Lancet 378, 124–125. Tejedor, M.C., Diaz, A., Castillon, J.J., Pericay, J.M., 1999. Attempted suicide: repetition and survival–findings of a follow-up study. Acta Psychiatr. Scand. 100, 205–211. Turhan, E., Inandi, T., Aslan, M., Zeren, C., 2011. Epidemiology of attempted suicide in Hatay, Turkey. Neurosciences (Riyadh) 16, 347–352. Valtonen, H., Suominen, K., Partonen, T., Ostamo, A., Lonnqvist, J., 2006. Time patterns of attempted suicide. J. Affect. Disord. 90, 201–207. Van Casteren, V., Van der Veken, J., Tafforeau, J., Van Oyen, H., 1993. Suicide and attempted suicide reported by general practitioners in Belgium, 1990–1991. Acta Psychiatr. Scand. 87, 451–455. Vijayakumar, L., Nagaraj, K., Pirkis, J., Whiteford, H., 2005. Suicide in developing countries (1): frequency, distribution, and association with socioeconomic indicators. Crisis 26, 104–111. Yip, P.S., Yang, K.C., 2004. A comparison of seasonal variation between suicide deaths and attempts in Hong Kong SAR. J. Affect. Disord. 81, 251–257. ten Have, M., de Graaf, R., van Dorsselaer, S., Verdurmen, J., van ‘t Land, H., Vollebergh, W., Beekman, A., 2009. Incidence and course of suicidal ideation and suicide attempts in the general population. Can. J. Psychiatry 54, 824–833.
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Research report
Rate of suicide and suicide attempts and their relationship to unemployment in Thessaloniki Greece (2000–2012) Konstantinos N. Fountoulakis a, Christos Savopoulos b,n, Martha Apostolopoulou c, Roxani Dampali d, Eleni Zaggelidou e, Eleni Karlafti f, Ilias Fountoukidis g, Pavlos Kountis h, Vasilis Limenopoulos i, Eustratios Plomaritis j, Pavlos Theodorakis k, Apostolos I Hatzitolios l a
3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Greece 1st Propedeutic Department of Internal Medicine, School of Medicine, Aristotle University, AHEPA Hospital, Thessaloniki, Greece c Internal Medicine Department, Agios Pavlos Hospital, Thessaloniki, Greece d Achladochori Prefectural Outpatient Clinic, Serres County, Greece e Forensic Service of Thessaloniki, Ministry of Justice, Thessaloniki, Greece f 1st Propedeutic Department of Internal Medicine, AHEPA Hospital, Thessaloniki, Greece g Internal Medicine Department, Agios Pavlos Hospital, Thessaloniki, Greece h Internal Medicine Department, “G. Gennimatas” Hospital, Thessaloniki, Greece i Department of Internal Medicine, “G. Gennimatas” Hospital, Thessaloniki, Greece j Department of Internal Medicine, Agios Pavlos Hospital, Thessaloniki, Greece k WHO National Counterpart for Mental Health, Greece l 1st Propedeutic Department of Internal Medicine, School of Medicine, Aristotle University, AHEPA Hospital, Thessaloniki, Greece b
art ic l e i nf o Article history: Received 21 June 2014 Received in revised form 20 November 2014 Accepted 22 November 2014 Available online 29 November 2014 Keywords: Suicide attempts Austerity Greece
Introduction: Recently there was a debate concerning the relationship between the economic crisis and an increase in attempted and completed suicides in Europe and especially in Greece. The aim of the current study was to calculate the rates of attempted and completed suicide per year in the county of Thessaloniki, Macedonia, northern Greece, for the years 2000–12, and to investigate their relationship with unemployment. Material and methods: The archive of the Emergency Outpatient Units of three hospitals was investigated and the results were projected to the county population. Data from the Hellenic statistics authority concerning regional general population and suicides and unemployment were used. Results: The rate of attempted suicides was 16.69–40.34 per 105 inhabitants for males and 41.43–110.82 for females. Medication was the preferred method for 95.93%. The completed suicide rates varied from 3.62 to 5.47 for males and from 0.19 to 1.95 per 105 inhabitants for females. The male attempt rate correlated negatively with regional male unemployment ( 0.63). For females the respected value was similar ( 0.72). Concerning competed suicide rates, the respected values were 0.34 and 0.65. The attempt was repeated by 15.34%; almost half-repeated within the same year and 75% within two years. The female to male ratio varied significantly across years with 2:1 (more females) being the probable value for attempts and 1:3.6 (more males) for completed suicides. Conclusion: This is the first study from Greece reporting rates on the basis of hospital archives. Attempt and suicide rates are low in Greece. Attempts are negatively and suicides are positively correlated with unemployment. & 2014 Elsevier B.V. All rights reserved.
1. Introduction
n
Corresponding author. E-mail addresses: [email protected] (K.N. Fountoulakis), [email protected] (C. Savopoulos), [email protected] (M. Apostolopoulou), [email protected] (R. Dampali), [email protected] (E. Karlafti), [email protected] (I. Fountoukidis), [email protected] (P. Kountis), [email protected] (V. Limenopoulos), [email protected] (P. Theodorakis), [email protected] (A. Hatzitolios). http://dx.doi.org/10.1016/j.jad.2014.11.047 0165-0327/& 2014 Elsevier B.V. All rights reserved.
Since 2008, Greece has entered a long period of economic crisis. This had serious adverse effects on various aspects of daily life and probably on the mental health of its citizens. It is very important that the Greek Ministry of Health reported that the annual suicide rate had increased by 40%, although at the time of this announcement no relevant data were available (Hellenic Statistical Authority, 2011; Kentikelenis et al., 2011). Following this, a telephone survey reported that there was a 36% increase in the number who reported having attempted suicide in the month
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Fig. 1. The pyramid of rates related with suicidality. ‘N’ stands for the proportion of persons in the different categories. E.g. for every 20 attempts a single competed suicide exists and this also corresponds to 1600 persons who currently are thinking that it is not worth living.
before the survey took place. This increase was from 1.1% in 2009 to 1.5% in 2011. Also high economic distress was more prevalent and it was correlated with suicidal ideation (Economou et al., 2011). In accord with the above another paper reported a 17% increase in suicidal rates during 2008–9 in Greece (Stuckler et al., 2011). A different picture was reported by the Greek Statistics Authority (ELSTAT) whose data did not suggest any increase in suicides until 2010 (Fountoulakis et al., 2012; Hellenic Statistical Authority, 2011). According to the ELSTAT data the first increase in suicidal rates appeared during 2011 (Fountoulakis et al., 2013a, 2013b). Attempts and reported attempts or suicidal ideation are quite different from completed suicide. Rates are also completely different. A recent paper from our group reported that in Greece, cross-sectionally and depending on the frequency, approximately 8% were thinking that it is not worth living, 6% had a past history of self-injury, 2% had a history of suicide attempts and 1.5% had current suicidal ideation (Fig. 1) (Fountoulakis et al., 2012). These results were collected before 2008, that is before the beginning of the current crisis and are in accord with the literature (Platt et al., 1992; Schmidtke et al., 1996). It is interesting to note an important discrepancy in the literature. Although it has been reported that 9.7% of adolescents have attempted and 29.9% had thought about suicide at some point (Platt et al., 1992; Schmidtke et al., 1996) the respected lifetime data collected during the adult life (which of course include attempts during adolescence) are somewhat lower, suggesting the presence of under-reporting. Several risk factors for the manifestation of any kind of suicidal behavior have been identified. These risk factors are classified as primary (such as the presence of psychiatric and medical conditions, severe somatic illness, previous suicide attempts), secondary (adverse life situations and psychosocial risk factors) and tertiary (demographic factors such as male gender and old age) (Henriksson et al., 1993; Rihmer et al., 2002). The aim of the current study was to calculate the rate of attempted suicide per year in the county of Thessaloniki, Greece, for the years 2000–12 on the basis of the registrations in the emergency outpatient units, and to investigate the relationship between attempts, suicides and unemployment in the same region.
2. Material and methods The archive of the 1st Propedeutic Department of Internal Medicine Emergency Outpatient Unit, of University Hospital AHEPA,
Thessaloniki Greece was searched for the period from January 1st, 2000 through December 31st, 2012, to identify cases of suicidal attempts. Also the archives of the respected outpatient clinics of the hospitals ‘Agios Pavlos’ and ‘G. Genimatas’ were searched for those specific time periods they were on duty jointly with AHEPA. The archives of one of the surgical departments were also searched but eventually not included because of a very low number of cases (o10 in total). The cases of suicidal attempts are registered by the medical staff on the basis of reports by the patient himself or the family but also by taking into consideration all the relevant clinical and laboratory features of the specific case. The analysis included descriptive statistics of the raw data (absolute numbers). The next step was to calculate the rates on the basis of the days of duty this group of hospitals undertook during the period studied. The method is described in details in the webappendix. ANOVA was used to test differences between populations, Correlations between regional unemployment rates and attempted and completed suicide rates were calculated. In detail the sources of data and the method are described in Part A of the webappendix. The analysis, along with the results are described in a step-by-step way in parts B, C and D of the webappendix.
3. Results The search of the archives identified 940 registrations of suicidal attempts during the years 2000–2012 940. These registrations corresponded to 919 individual persons (females: N ¼ 651, 70.84%; males: N ¼ 268, 29.16%). The mean age was 34.99 716.91 (range 15–90) years for females and 39.69 718.35 (range 15–95) years for males. All of them survived the attempt. The numbers of attempts concerning each sex in each year and the respected female-to-male ratio (with the use of absolute raw numbers) are shown in webappendix- Table I. The vast majority (94.26%) attempted by using medication pills (webappendix Table II). Males preferred more violent ways (e.g. 6.88% males vs. 3.31% females attempted with toxic substances, 0.72% vs. 0.15% fell into the sea) but the numbers were too small for statistical testing. The calculated rates of suicidal attempts varied from 29.57 (for 2011) to 70.77 per 105 inhabitants (for 2006). The detailed rates by sex and year are shown in Table 1.
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Table 1 Rates of regional unemployment, suicide rates and completed suicides in the two sexes Unv¼ unavailable. year Males Regional unemployment 2000 8.7 2001 7.5 2002 8.4 2003 6.7 2004 7 2005 7.3 2006 6.5 2007 6.1 2008 5.4 2009 8.9 2010 10.4 2011 16.8 2012 24.7 a
Females Estimate rate attempts per year
Rate of suicides per year
Regional unemployment
23.37 38.96 34.23 35.65 26.40
3.67 3.62 3.80 5.09 5.06 5.47 3.69 4.52 3.85 4.67 4.23 5.07 4.22a
18.1 16.7 17.1 14.5 17.8 18.1 14.1 12.9 14 14.7 16.1 24.3 30.1
27.33 37.26 38.71 40.34 34.23 16.69 31.68
Estimate rate attempts per year 65.50 71.87 84.45 59.76 49.48 110.82 85.96 80.19 85.24 76.86 41.43 59.33
Rate of suicides per year 1.47 1.04 1.44 1.02 1.62 1.21 0.40 0.99 1.18 1.17 0.19 1.95 1.36a
Calculated on the same general population as previous year.
The distribution of attempts per month of year showed the presence of clear peaks during May and August, that is at the border of summer, and troughs in February and December that is at the border of winter Twenty one persons (2.28%) attempted twice (8 males, 38.10% and 13 females, 61.90%), but this is not the actual number since some second attempts could had been registered in the days of duty of another hospital. The projection suggested that a total of 141 patients out of 919 of our sample (15.34%) had attempted for a second time (webappendix Table X). The current study did not investigate whether any subjects died as a consequence of suicide after their first attempt. ANOVA with number of attempts and sex as grouping variables revealed no main effect for either variable alone or for their interaction concerning age (p4 0.05). Proportionally more males than females attempted for a second time, but the difference was not significant (χ2 ¼ 0.83, df ¼1, p ¼0.362) The time to second attempt did not differ between sexes (df ¼1, F¼ 0.656, p ¼0.428). Almost half (47.62%) committed the second attempt within the same year and an additional 23.81% within the next year. Each next year accounted for 4.76% of cases. Thus, almost half of those reattempted have done so within the same year and 75% within two years. The completed suicide rates for the years 2000–2012 are shown in Table 1. The male to female ratio varied significantly across years with an average of 5.6:1. If the years 2006 and 2010 are not taken into account (because they constitute outliers with extremely low female numbers) this ratio falls to 3.6:1 (webappendix Table XI). The male attempt rate correlated negatively with regional male unemployment ( 0.63). For females the respective value similar ( 0.72). Concerning competed suicide rates, the respective values were 0.34 and 0.65. Male attempts showed a weak negative correlation with male ( 0.21) and female suicide rates ( 0.45), while female attempts showed a strong negative correlation (4 0.60) with both male and female suicide rates. The complete matrix of correlations is shown in webappendix Table XIII. A more detailed presentation of results can be found in the webappendix.
4. Discussion The current study reports that the rates of attempted suicides in Thessaloniki, Greece for the years 2000–2012 were between 16.69 and 40.34 per 105 inhabitants for males and from 41.43 to
110.82 for females. Concerning the method, 95.93% attempted with medications. The rates were higher for the years 2006–9, but no clear tendency in relationship to time was present. The suicide rates varied from 3.62 to 5.47 for males and from 0.19 to 1.95 per 105 inhabitants for females and they were higher for the period 2003–5 and for the year 2011. Peculiarly, there was a strong negative relationship of attempts with unemployment, which explains the 2006–9 peak. On the contrary, suicide rates were positively correlated with unemployment. Two peaks were identified for attempts, and they were in May and August that is at the border of summer. There were also two troughs present, in February and December that is at the border of winter. It has been estimated that 15.34% of persons who attempted once, repeated the attempt and almost half of them had done so within the same year. Within two years 75% of those who repeated the attempt had done so. The female to male ratio varied significantly across years with 2:1 (more females) being the probable value for attempts and 1:3.6 (more males) for completed suicides. There is a bulk of data from several countries from around the world which suggest that the suicide attempt rates vary widely. One WHO multinational study reported an average rate of 300 attempts per 105 residents for the years 2001–2007 with no difference between developing and developed countries (Borges et al., 2010). Another WHO study reported that in Europe the highest average male age-standardized rate of suicide attempts was found for Helsinki, Finland (314/105), and the lowest rate was found for Guipuzcoa, Spain (45/105) (Schmidtke et al., 1996). However, often studies report significantly different results even when they come from the same country and concern the same time period. For example for Turkey, rates for males vary from 31.9 to 46.89 and for females from 60.42 to 112.89 per 105 inhabitants (Devrimci-Ozguven and Sayil, 2003; Sayil and Devrimci-Ozguven, 2002; Turhan et al., 2011). This is especially striking in the US where the rates vary by state. With an average of 500 per 105 inhabitants across the country, the variability is great with rates ranging from 100 in Delaware and Georgia to 1500 per 105 inhabitants in Rhode Island (Baca-Garcia et al., 2003; Birkhead et al., 1993; Borges et al., 2006; Crosby et al., 1999; Crosby et al., 2011; Kessler et al., 2005; Kuo et al., 2001; Roesler et al., 2009). Race might also play an important role with blacks attempting 1.5–2 more in comparison to Caucasians and Hispanics (Birkhead et al., 1993; Prosser et al., 2007). The rates from the other anglo-saxon countries vary with Australia and New Zealand averaging 400 attempts per 105 inhabitants (Beautrais et al., 2006; Fairweather-Schmidt and Anstey,
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2011; Johnston et al., 2009; Pirkis et al., 2000) while the UK had somewhat lower rates (males 211–280, females 296–497, for 1976– 1990; no change for men, decline over the years for women) (Hawton and Fagg, 1992). Canada had the lowest rate for the years 1998–2000 (76.1 for females and 60.3 per 105 inhabitants for males) (Alaghehbandan et al., 2005) For the Netherlands, the reported rates vary widely from below 50 up to 300 per 105 inhabitants (Arensman et al., 1995; Marquet et al., 2005; ten Have et al., 2009). For Denmark the rate is probably around 500 (Kjoller and Helweg-Larsen, 2000), while for Belgium the data are more consistent with rates around 60–70 for males and 70–140 per 105 inhabitants for females (Boffin et al., 2011; Bossuyt and Van Casteren, 2007; Van Casteren et al., 1993). These rates are generally similar to the rates reported concerning Germany (Bogdanovica et al., 2010) and Sweden (Bogdanovica et al., 2010). Ireland and Latvia reported rates slightly above 150,300 per 105 inhabitants (Arensman et al., 1995; Corcoran et al., 2004; Marquet et al., 2005; Rancans et al., 2001; ten Have et al., 2009). Unfortunately concerning Italy the data vary so much that they should not be considered to be reliable (Majori et al., 2004; Poma et al., 2007). There is a lack of data concerning the rest of the world. There are some reports which suggest that the rate for China was 160 per 105 inhabitants for the years 1995–1999 (2004), for Israel the rate was 16.7 105 inhabitants (Arabs, 24.4 and Jews, 11.0) for the years 1996–7 (Ashkar et al., 2006) and for Brazil the rate was probably around 400 per 105 inhabitants (Botega et al., 2005). Taking into consideration the international rates mentioned above, it is clear that the rates reported in the current study are one of the lowest rates for suicidal attempts in the world. This is in accord with the data coming from other Mediterranean countries. It is interesting to note that the use of medication in our study was overwhelmingly high, but it is unlikely that this constitutes a bias or limitation. Also an issue open for debate is the very low number of surgical cases. There are previous reports from Greece on the epidemiology of attempted suicide using different methods and indices. In the first one, an epidemiological interviewer-based method was used and reported the prevalence of attempted suicide for the year prior to interview. These rates were 0.27% for males and 1.10% for females for the year 1978 and 1.5% and 3.4% respectively for the year 1984 (Madianos et al., 1993). Although similar figures are reported in the literature concerning other countries, these data cannot be compared to those of the current study. If one extrapolates the 1978 figures into rates per 105 inhabitants, the figures are 10-fold higher for males and 15-fold or more for females in comparison to our findings. The figures from 1984 are even higher. This is a problem of different methodologies and it is widespread in the literature. More recent studies calculated the rates for the period 2009–2011 by using a telephone survey method. They reported an increase in reported suicide attempts from 1.1% (for 2009) to 1.5% (for 2011) for the month previous to the interviewing (Economou et al., 2013, 2011). In these latter two studies the ‘previous month’ attempt rate is almost similar to the rate reported in the 1978–84 study concerning the ‘previous year’. This later observation is important because a rate of 1.1–1.5% per month implies that (after taking into consideration repeating of attempts also) approximately 10–18% of the population will attempt within a year, raising the absolute numbers to millions. Probably the subjects could not focus their responses on the previous month or even year, and instead many of them reported their lifetime experience. They also might had reported simple self-destructive acts or even suicidal ideation as attempts. It should be noted that 1% per month of the 18þpopulation in Greece (approx. 6 million) corresponds to 2000 attempts per day and to ¾ of a million per year (12,500 per 105 inhabitants). Similarly, 1% per year corresponds to 1000 per 105 inhabitants.
In the literature, the reported rate of female to male attempts varies from 2–3:1 to even 1:1 in more recent studies (Alaghehbandan et al., 2005; Baydin et al., 2005; Bille-Brahe et al., 1997; Bogdanovica et al., 2010; De Leo et al., 2001; Fushimi et al., 2006; Hawton and Fagg, 1992; Hulten et al., 2001; Kovess-Masfety et al., 2011; Majori et al., 2004; Marquet et al., 2005; Rancans et al., 2001). It is possible that women do not attempt suicide more frequently than men, except for 13–26 year olds (Levinson et al., 2006). The current study reports that the most probable ratio for Greece is 2:1 but with significant variability between years, and the trend is a decline of the ratio. This is more or less in accord with previous studies suggested that in Greece during 1971–72 the ratio of female to male in persons who attempted was 4.6:1 and it had fell to 2.3:1 in 1994–96 (Ierodiakonou et al., 1998) An important limitation of the current study but also for the literature in general is that the majority of attempts might not reach the emergency room and they are not even seen by a health professional. It has been reported that less than 30% go to the hospital (De Leo et al., 2005) and no more than 50–60% become known to the healthcare system (Kjoller and Helweg-Larsen, 2000). Probably one third consults a medical practitioner and one fifth a psychiatrist. (Ma et al., 2009). This probably means that the real attempt rate in Greece is triple than the one reported by the current study. An important confounder in the current study is the fact that for the years 2005–9 a different system for the treatment of emergency cases was in place. It is unknown how this could have affected the data since proximity is a factor which can determine seeking help after an attempt. In terms of risk factors, there are two studies which identified current unemployment as a risk factor (OR¼2–4) but both suggested it is not a primary cause (Beautrais et al., 1998; Fergusson et al., 2007). Another one found no effect of unemployment (Lorensini and Bates, 2002). Low income seems to correlate with attempts (Kalist et al., 2007). Other risk factors include age (425 years), female sex, race, unmarried status, lower education level, lower or higher monthly income and presence of major mental and medical disorders (Ma et al., 2009; Majori et al., 2004; Mazza et al., 2011; McMillan et al., 2010; Nock and Kessler, 2006; Pirkis et al., 2000). The current study, reports a negative correlation between attempts and regional unemployment, while on the contrary the correlation is positive between completed suicides and unemployment. This was true both for males and females. Additionally, there was a strong negative correlation between female attempts and female suicides while the respective correlation was weak in males. All the above suggests that female attempts are not only higher in rate in comparison to male attempts but they might also differ in quality. This might mean that female attempts could be potentially more serious in terms of intention. Although the literature is limited, it seems that internationally, medication seems to be the dominant method of attempting (Hatzitolios et al., 2001; Jaraczewska and Czerczak, 1994) followed by pesticides. This dominance of medication is especially evident in high income countries (Kawashima et al., 2014) while data related to suicides in low and middle income countries are fairly limited (Milner and De Leo, 2010; Vijayakumar et al., 2005). On the other hand, in low income countries pesticides seem to be the dominant method (Fleischmann et al., 2005). This could well reflect a difference between countries concerning access to potentially poisonous substances. In the current study the overall dominance of medication use was remarkable and above 95%, but it is unlikely it constitutes a limitation of the study. While the current study reports that 15.34% of people who attempted once repeat the attempt with half of them doing so within the first year, the literature suggests that around 8% repeat the attempt within one year, and this is perfectly in accord with our
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results (Corcoran et al., 2004; Dieserud et al., 2010; Hulten et al., 2001). It has also been reported that to 44% repeats the attempt within 8–10 years (Christiansen and Jensen, 2007; Groholt and Ekeberg, 2009; Tejedor et al., 1999). Finally, there are reports on a seasonal pattern in the rate of suicide attempts with peaks during the spring and summer and troughs during the autumn and winter. However the data are complex and a number of confounding variables exist, including gender, social cues and diagnosis (Baydin et al., 2005; Hiltunen et al., 2012; Jessen et al., 1999; Kordic et al., 2010; Mergl et al., 2010; Preti and Miotto, 2000; Valtonen et al., 2006; Yip and Yang, 2004). Our results identified specific months, are generally in accord with a summer peak and winter low, but the findings were somewhat inconsistent across years Role of funding source None.
Conflict of interest None.
Acknowledgments None.
Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jad.2014.11.047. References Alaghehbandan, R., Gates, K.D., MacDonald, D., 2005. Suicide attempts and associated factors in Newfoundland and Labrador, 1998–2000. Can. J. Psychiatry 50, 762–768. Arensman, E., Kerkhof, A.J., Hengeveld, M.W., Mulder, J.D., 1995. Medically treated suicide attempts: a four year monitoring study of the epidemiology in The Netherlands. J. Epidemiol. Community Health 49, 285–289. Ashkar, K., Giloni, C., Grinshpoon, A., Geraisy, N., Gruner, E., Cohen, R., Paryente, O., Nassar, F., Ponizovsky, A.M., 2006. Suicidal attempts admitted to a general hospital in the Western Galilee: an inter-ethnic comparison study. Isr. J. Psychiatry Relat. Sci. 43, 137–145. Baca-Garcia, E., Diaz-Sastre, C., Ceverino, A., Saiz-Ruiz, J., Diaz, F.J., de Leon, J., 2003. Association between the menses and suicide attempts: a replication study. Psychosom. Med. 65, 237–244. Baydin, A., Yardan, T., Aygun, D., Doganay, Z., Nargis, C., Incealtin, O., 2005. Retrospective evaluation of emergency service patients with poisoning: a 3-year study. Adv. Ther. 22, 650–658. Beautrais, A.L., Joyce, P.R., Mulder, R.T., 1998. Unemployment and serious suicide attempts. Psychol. Med. 28, 209–218. Beautrais, A.L., Wells, J.E., McGee, M.A., Oakley Browne, M.A., 2006. Suicidal behaviour in Te Rau Hinengaro: the New Zealand Mental Health Survey. Aust. N. Z. J. Psychiatry 40, 896–904. Bille-Brahe, U., Kerkhof, A., De Leo, D., Schmidtke, A., Crepet, P., Lonnqvist, J., Michel, K., Salander-Renberg, E., Stiles, T.C., Wasserman, D., Aagaard, B., Egebo, H., Jensen, B., 1997. A repetition-prediction study of European parasuicide populations: a summary of the first report from part II of the WHO/EURO Multicentre Study on Parasuicide in co-operation with the EC concerted action on attempted suicide. Acta Psychiatr. Scand. 95, 81–86. Birkhead, G.S., Galvin, V.G., Meehan, P.J., O'Carroll, P.W., Mercy, J.A., 1993. The emergency department in surveillance of attempted suicide: findings and methodologic considerations. Public Health Rep. 108, 323–331. Boffin, N., Bossuyt, N., Vanthomme, K., Van Casteren, V., 2011. Declining rates of suicidal behavior among general practice patients in Belgium: results from sentinel surveillance between 1993 and 2008. Arch. Suicide Res. 15, 68–74. Bogdanovica, I., Jiang, G.X., Lohr, C., Schmidtke, A., Mittendorfer-Rutz, E., 2010. Changes in rates, methods and characteristics of suicide attempters over a 15-year period: comparison between Stockholm, Sweden, and Wurzburg, Germany. Soc. Psychiatry Psychiatr. Epidemiol. 46, 1103–1114. Borges, G., Angst, J., Nock, M.K., Ruscio, A.M., Walters, E.E., Kessler, R.C., 2006. A risk index for 12-month suicide attempts in the National Comorbidity Survey Replication (NCS-R). Psychol. Med. 36, 1747–1757. Borges, G., Nock, M.K., Haro Abad, J.M., Hwang, I., Sampson, N.A., Alonso, J., Andrade, L.H., Angermeyer, M.C., Beautrais, A., Bromet, E., Bruffaerts, R., de Girolamo, G., Florescu, S., Gureje, O., Hu, C., Karam, E.G., Kovess-Masfety, V.,
135
Lee, T., Levinson, D., Medina-Mora, M.E., Ormel, J., Posada-Villa, J., Sagar, R., Tomov, T., Uda, H., Williams, D.R., Kessler, R.C., 2010. Twelve-month prevalence of and risk factors for suicide attempts in the World Health Organization World Mental Health Surveys. J. Clin. Psychiatry 71, 1617–1628. Bossuyt, N., Van Casteren, V., 2007. Epidemiology of suicide and suicide attempts in Belgium: results from the sentinel network of general practitioners. Int. J. Public Health 52, 153–157. Botega, N.J., Barros, M.B., Oliveira, H.B., Dalgalarrondo, P., Marin-Leon, L., 2005. Suicidal behavior in the community: prevalence and factors associated with suicidal ideation. Rev. Bras. Psiquiatr. 27, 45–53. Christiansen, E., Jensen, B.F., 2007. Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: a register-based survival analysis. Aust. N. Z. J. Psychiatry 41, 257–265. Corcoran, P., Keeley, H.S., O’Sullivan, M., Perry, I.J., 2004. The incidence and repetition of attempted suicide in Ireland. Eur. J. Public Health 14, 19–23. Crosby, A.E., Cheltenham, M.P., Sacks, J.J., 1999. Incidence of suicidal ideation and behavior in the United States, 1194. Suicide Life Threat. Behav. 29, 131–140. Crosby, A.E., Han, B., Ortega, L.A., Parks, S.E., Gfroerer, J., 2011. Suicidal thoughts and behaviors among adults aged Z 18 years – United States, 2008–2009. MMWR Surveill. Summ. 60, 1–22. De Leo, D., Cerin, E., Spathonis, K., Burgis, S., 2005. Lifetime risk of suicide ideation and attempts in an Australian community: prevalence, suicidal process, and help-seeking behaviour. J. Affect. Disord. 86, 215–224. De Leo, D., Padoani, W., Scocco, P., Lie, D., Bille-Brahe, U., Arensman, E., Hjelmeland, H., Crepet, P., Haring, C., Hawton, K., Lonnqvist, J., Michel, K., Pommereau, X., Querejeta, I., Phillipe, J., Salander-Renberg, E., Schmidtke, A., Fricke, S., Weinacker, B., Tamesvary, B., Wasserman, D., Faria, S., 2001. Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour. Int. J. Geriatr. Psychiatry 16, 300–310. Devrimci-Ozguven, H., Sayil, I., 2003. Suicide attempts in Turkey: results of the WHO-EURO Multicentre Study on Suicidal Behaviour. Can. J. Psychiatry 48, 324–329. Dieserud, G., Gerhardsen, R.M., Van den Weghe, H., Corbett, K., 2010. Adolescent suicide attempts in Baerum, Norway, 1984-2006. Crisis 31, 255–264. Economou, M., Madianos, M., Peppou, L.E., Theleritis, C., Patelakis, A., Stefanis, C., 2013. Suicidal ideation and reported suicide attempts in Greece during the economic crisis. World Psychiatry 12, 53–59. Economou, M., Madianos, M., Theleritis, C., Peppou, L.E., Stefanis, C.N., 2011. Increased suicidality amid economic crisis in Greece. Lancet 378, 1459. Fairweather-Schmidt, A.K., Anstey, K.J., 2011. Prevalence of suicidal behaviours in two Australian general population surveys: methodological considerations when comparing across studies. Soc. Psychiatry Psychiatr. Epidemiol. 47, 515–522. Fergusson, D.M., Boden, J.M., Horwood, L.J., 2007. Unemployment and suicidal behavior in a New Zealand birth cohort: a fixed effects regression analysis. Crisis 28, 95–101. Fleischmann, A., Bertolote, J.M., De Leo, D., Botega, N., Phillips, M., Sisask, M., Vijayakumar, L., Malakouti, K., Schlebusch, L., De Silva, D., Nguyen, V.T., Wasserman, D., 2005. Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middleincome countries. Psychol. Med. 35, 1467–1474. Fountoulakis, K.N., Grammatikopoulos, I.A., Koupidis, S.A., Siamouli, M., Theodorakis, P.N., 2012. Health and the financial crisis in Greece. Lancet 379, 1001–1002 (author reply 1002). Fountoulakis, K.N., Koupidis, S.A., Grammatikopoulos, I.A., Theodorakis, P.N., 2013a. First reliable data suggest a possible increase in suicides in Greece. BMJ 347, f4900. Fountoulakis, K.N., Koupidis, S.A., Siamouli, M., Grammatikopoulos, I.A., Theodorakis, P.N., 2013b. Suicide, recession, and unemployment. Lancet 381, 721–722. Fushimi, M., Sugawara, J., Saito, S., 2006. Comparison of completed and attempted suicide in Akita, Japan. Psychiatry Clin. Neurosci. 60, 289–295. Groholt, B., Ekeberg, O., 2009. Prognosis after adolescent suicide attempt: mental health, psychiatric treatment, and suicide attempts in a nine-year follow-up study. Suicide Life Threat. Behav. 39, 125–136. Hatzitolios, A.I., Sion, M.L., Eleftheriadis, N.P., Toulis, E., Efstratiadis, G., Vartzopoulos, D., Ziakas, A.G., 2001. Parasuicidal poisoning treated in a Greek medical ward: epidemiology and clinical experience. Hum. Exp. Toxicol. 20, 611–617. Hawton, K., Fagg, J., 1992. Trends in deliberate self poisoning and self injury in Oxford, 1976-90. BMJ 304, 1409–1411. Hellenic Statistical Authority, 2011. December 2011. Monthly Statistical Bulletin, 56, 15. Henriksson, M.M., Aro, H.M., Marttunen, M.J., Heikkinen, M.E., Isometsa, E.T., Kuoppasalmi, K.I., Lonnqvist, J.K., 1993. Mental disorders and comorbidity in suicide. Am. J. Psychiatry 150, 935–940. Hiltunen, L., Ruuhela, R., Ostamo, A., Lonnqvist, J., Suominen, K., Partonen, T., 2012. Atmospheric pressure and suicide attempts in Helsinki, Finland. Int. J. Biometeorol.. Hulten, A., Jiang, G.X., Wasserman, D., Hawton, K., Hjelmeland, H., De Leo, D., Ostamo, A., Salander-Renberg, E., Schmidtke, A., 2001. Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors. Eur. Child Adolesc. Psychiatry 10, 161–169. Ierodiakonou, C.S., Iacovides, A., Ierodiakonou-Benou, I., 1998. Changing patterns of attempted suicide in Greece: clinicoepidemiological and psychodynamic data. Psychopathology 31, 281–292. Jaraczewska, W., Czerczak, S., 1994. The pattern of acute poisonings in Poland. Vet. Hum. Toxicol. 36, 228–233.
136
K.N. Fountoulakis et al. / Journal of Affective Disorders 174 (2015) 131–136
Jessen, G., Jensen, B.F., Arensman, E., Bille-Brahe, U., Crepet, P., De Leo, D., Hawton, K., Haring, C., Hjelmeland, H., Michel, K., Ostamo, A., Salander-Renberg, E., Schmidtke, A., Temesvary, B., Wasserman, D., 1999. Attempted suicide and major public holidays in Europe: findings from the WHO/EURO multicentre study on parasuicide. Acta Psychiatr. Scand. 99, 412–418. Johnston, A.K., Pirkis, J.E., Burgess, P.M., 2009. Suicidal thoughts and behaviours among Australian adults: findings from the 2007 National Survey of Mental Health and Wellbeing. Aust. N. Z. J. Psychiatry 43, 635–643. Kalist, D.E., Molinari, N.A., Siahaan, F., 2007. Income, employment and suicidal behavior. J. Ment. Health Policy Econ. 10, 177–187. Kawashima, Y., Yonemoto, N., Inagaki, M., Yamada, M., 2014. Prevalence of suicide attempters in emergency departments in Japan: a systematic review and metaanalysis. J. Affect. Disord. 163, 33–39. Kentikelenis, A., Karanikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D., 2011. Health effects of financial crisis: omens of a Greek tragedy. Lancet 378, 1457–1458. Kessler, R.C., Berglund, P., Borges, G., Nock, M., Wang, P.S., 2005. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 293, 2487–2495. Kjoller, M., Helweg-Larsen, M., 2000. Suicidal ideation and suicide attempts among adult Danes. Scand. J. Public Health 28, 54–61. Kordic, M., Babic, D., Petrov, B., Kordic, J., Jelavic, B., Pivic, G., 2010. The meteorological factors associated with suicide. Coll. Antropol. 34 (Suppl 1), S151–S155. Kovess-Masfety, V., Boyd, A., Haro, J.M., Bruffaerts, R., Villagut, G., Lepine, J.P., Gasquet, I., Alonso, J., 2011. High and low suicidality in Europe: a fine-grained comparison of France and Spain within the ESEMeD surveys. J. Affect. Disord. 133, 247–256. Kuo, W.H., Gallo, J.J., Tien, A.Y., 2001. Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland. Psychol. Med. 31, 1181–1191. Levinson, D., Haklai, Z., Stein, N., Gordon, E.S., 2006. Suicide attempts in israel: age by gender analysis of a national emergency departments database. Suicide Life Threat. Behav. 36, 97–102. Lorensini, S., Bates, G., 2002. Relationship difficulties and unemployment in attempted suicide in an Australian regional center. Psychol. Rep. 90, 923–929. Ma, X., Xiang, Y.T., Cai, Z.J., Li, S.R., Xiang, Y.Q., Guo, H.L., Hou, Y.Z., Li, Z.B., Li, Z.J., Tao, Y.F., Dang, W.M., Wu, X.M., Deng, J., Chan, S.S., Ungvari, G.S., Chiu, H.F., 2009. Lifetime prevalence of suicidal ideation, suicide \plans and attempts in rural and urban regions of Beijing, China. Aust. N. Z. J. Psychiatry 43, 158–166. Madianos, M.G., Madianou-Gefou, D., Stefanis, C.N., 1993. Changes in suicidal behavior among nation-wide general population samples across Greece. Eur. Arch. Psychiatry Clin. Neurosci. 243, 171–178. Majori, S., Zanin, G., Benvenuti, K., Tardivo, S., Cristofoletti, M., Baldo, V., 2004. Attempted suicides in the municipality of Padua (Italy): a retrospective survey (1996–2000). Ann. Ig. 16, 685–692. Marquet, R.L., Bartelds, A.I., Kerkhof, A.J., Schellevis, F.G., van der Zee, J., 2005. The epidemiology of suicide and attempted suicide in Dutch General Practice 1983– 2003. BMC. Fam. Pract. 6, 45. Mazza, J.J., Catalano, R.F., Abbott, R.D., Haggerty, K.P., 2011. An examination of the validity of retrospective measures of suicide attempts in youth. J. Adolesc. Health 49, 532–537. McMillan, K.A., Enns, M.W., Asmundson, G.J., Sareen, J., 2010. The association between income and distress, mental disorders, and suicidal ideation and attempts: findings from the Collaborative Psychiatric Epidemiology Surveys. J. Clin. Psychiatry 71, 1168–1175. Mergl, R., Havers, I., Althaus, D., Rihmer, Z., Schmidtke, A., Lehfeld, H., Niklewski, G., Hegerl, U., 2010. Seasonality of suicide attempts: association with gender. Eur. Arch. Psychiatry Clin. Neurosci. 260, 393–400.
Milner, A., De Leo, D., 2010. Suicide research and prevention in developing countries in Asia and the Pacific. Bull. World Health Organ. 88, 795–796. Nock, M.K., Kessler, R.C., 2006. Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. J. Abnorm. Psychol. 115, 616–623. Pirkis, J., Burgess, P., Dunt, D., 2000. Suicidal ideation and suicide attempts among Australian adults. Crisis 21, 16–25. Platt, S., Bille-Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T., Crepet, P., De Leo, D., Haring, C., Lonnqvist, J., Michel, K., et al., 1992. Parasuicide in Europe: the WHO/ EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr. Scand. 85, 97–104. Poma, S.Z., Magno, N., Belletti, S., Toniolo, E., 2007. Parasuicide in Rovigo (North of Italy) during the period 2000–2005. J. Prev. Med. Hyg. 48, 79–82. Preti, A., Miotto, P., 2000. Influence of method on seasonal distribution of attempted suicides in italy. Neuropsychobiology 41, 62–72. Prosser, J.M., Perrone, J., Pines, J.M., 2007. The epidemiology of intentional non-fatal self-harm poisoning in the United States: 2001–2004. J. Med. Toxicol. 3, 20–24. Rancans, E., Alka, I., Renberg, E.S., Jacobsson, L., 2001. Suicide attempts and serious suicide threats in the city of Riga and resulting contacts with medical services. Nord. J. Psychiatry 55, 279–286. Rihmer, Z., Belso, N., Kiss, K., 2002. Strategies for suicide prevention. Curr. Opin. Psychiatry 15, 83–87. Roesler, J., Petcoff, M., Azam, A., Westberg, S., Kinde, M., Crosby, A., 2009. Nonfatal suicide attempts and other self-inflicted harm. Beltrami County youths, 2002–2006. Minn. Med. 92, 53–55. Sayil, I., Devrimci-Ozguven, H., 2002. Suicide and suicide attempts in Ankara in 1998: results of the WHO/EURO multicentre study of suicidal behaviour. Crisis 23, 11–16. Schmidtke, A., Bille-Brahe, U., DeLeo, D., Kerkhof, A., Bjerke, T., Crepet, P., Haring, C., Hawton, K., Lonnqvist, J., Michel, K., Pommereau, X., Querejeta, I., Phillipe, I., Salander-Renberg, E., Temesvary, B., Wasserman, D., Fricke, S., Weinacker, B., Sampaio-Faria, J.G., 1996. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992 (Results of the WHO/EURO Multicentre Study on Parasuicide). Acta Psychiatr. Scand. 93, 327–338. Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., McKee, M., 2011. Effects of the 2008 recession on health: a first look at European data. Lancet 378, 124–125. Tejedor, M.C., Diaz, A., Castillon, J.J., Pericay, J.M., 1999. Attempted suicide: repetition and survival–findings of a follow-up study. Acta Psychiatr. Scand. 100, 205–211. Turhan, E., Inandi, T., Aslan, M., Zeren, C., 2011. Epidemiology of attempted suicide in Hatay, Turkey. Neurosciences (Riyadh) 16, 347–352. Valtonen, H., Suominen, K., Partonen, T., Ostamo, A., Lonnqvist, J., 2006. Time patterns of attempted suicide. J. Affect. Disord. 90, 201–207. Van Casteren, V., Van der Veken, J., Tafforeau, J., Van Oyen, H., 1993. Suicide and attempted suicide reported by general practitioners in Belgium, 1990–1991. Acta Psychiatr. Scand. 87, 451–455. Vijayakumar, L., Nagaraj, K., Pirkis, J., Whiteford, H., 2005. Suicide in developing countries (1): frequency, distribution, and association with socioeconomic indicators. Crisis 26, 104–111. Yip, P.S., Yang, K.C., 2004. A comparison of seasonal variation between suicide deaths and attempts in Hong Kong SAR. J. Affect. Disord. 81, 251–257. ten Have, M., de Graaf, R., van Dorsselaer, S., Verdurmen, J., van ‘t Land, H., Vollebergh, W., Beekman, A., 2009. Incidence and course of suicidal ideation and suicide attempts in the general population. Can. J. Psychiatry 54, 824–833.
